Outcomes of referrals by community optometrists to a hospital glaucoma service

An education-based intervention investigating the accuracy of community-based optometrists evaluating limbal anterior chamber depth

INTRODUCTION

In the UK, referrals for suspected primary angle closure (PAC) by community-based optometrists (CBO) to the hospital eye service show moderate accuracy. This study aimed to assess the interobserver agreement of limbal anterior chamber depth (LACD) between CBOs and ophthalmologists and evaluate the impact of an education intervention.

METHODS

Using a 7-point LACD grading scale, consultant ophthalmologists graded an LACD image dataset developed from 100 patients attending Moorfields Eye Hospital. Two sets of 84 images were utilised for two LACD online assessments. CBO were recruited and undertook assessments before and after a PAC education package (EP) between August 2023 and January 2024.

RESULTS

Fifty-two optometrists completed the initial LACD assessment with a median of 19.0 (IQR 9.3-24.8) years post-registration experience. Using the 7-point LACD grading scale, mean weighted kappa (Kw) for pre-EP was moderate, 0.42 (95% CI, 0.36-0.48), increasing to 0.47 (0.42-0.53) post-EP. Conversion to the 4-point grading scale, Kw was substantial, pre-EP 0.61, (0.56-0.66) and post-EP Kw 0.64 (0.58-0.69). An LACD threshold (<25%) sensitivity and specificity pre-EP was 86.0% (79.9-91.3%) and 84.6 (82.3-86.9), respectively. Post-EP sensitivity decreased to 78.2% (74.1-85.1%) (p = 0.049) but specificity increased to 90.4 (88.1-92.8) (p < 0.001).

CONCLUSION

The 4-point LACD grading scale would be more applicable for a case-finding setting. An accessible EP improved agreement and specificity using the joint Royal College of Ophthalmologists/College of Optometrists PAC referral threshold. This EP may reduce false positive PAC referrals and could be rapidly disseminated to CBO. Further research is needed to assess real-world PAC referrals after an education intervention.

Outcomes of Glaucoma Referrals in Adults Aged 18 to 40 Years

Importance

While early detection of glaucoma is vital to prevent irreversible vision loss, there are sparse data on the effectiveness of glaucoma referrals and methods to establish evidence-based referral guidelines in large, diverse populations.

Objective

To assess the prevalence and risk factors for diagnosed glaucoma and loss to follow-up among adult patients aged 18 to 40 years after a new diagnosis of referable glaucoma (ie, with glaucoma or suspected glaucoma).

Design, Setting, and Participants

This retrospective cohort study included patients aged 18 to 40 years presenting to Kaiser Permanente Southern California, a large managed health care system, for first-time eye examinations between January 1, 2013, and December 31, 2018. Data analysis occurred between September 2022 and August 2024.

Main Outcomes and Measures

The primary outcome was glaucoma diagnosed within 2 years of the first eye examination. The secondary outcome was the loss to follow-up, defined as failure to receive a glaucoma evaluation with visual field or optical coherence tomography testing within 2 years.

Results

The cohort included 292 453 patients aged 18 to 40 years who underwent first-time eye evaluations (mean [SD] age, 29.8 [6.4] years). Among 12 050 identified patients with referable glaucoma (52.3% female), 6827 (56.7%) completed glaucoma evaluations, of whom 563 (8.2%) were diagnosed with glaucoma (344 [61.1%] with open angle, 28 [5.0%] with angle closure, 84 [14.9%] with secondary glaucoma, and 107 [19.0%] with unspecified glaucoma). On multivariable analysis, male sex (odds ratio [OR], 1.55 [95% CI, 1.07-2.27]), higher intraocular pressure (IOP) (OR, 1.19 [95% CI, 1.15-1.23] per 1 mm Hg), and greater cup-disc ratio (CDR) (OR, 1.53 [95% CI, 1.34-1.75] per 0.1 unit) were associated with greater odds of glaucoma. Dichotomized age, IOP, and CDR models stratified 51 of 1613 patients (3.2%) into the low-risk group and 202 of 1477 patients (13.7%) into the high-risk group. Being younger than 32 years and having an IOP less than 18 mm Hg and a CDR less than 0.7 yielded a negative predictive value of 98.2% for a glaucoma diagnosis.

Conclusions and Relevance

In this cohort study, the diagnostic yield of glaucoma referrals was low among adults aged 18 to 40 years with first-time eye examinations. A simple risk-stratification strategy could help identify individuals with low and high risks of developing glaucoma, and adoption of evidence-based risk stratification and referral guidelines by health care systems and clinicians could improve equity of glaucoma care and use of eye-care resources.

Evaluating referrals of flashing lights and floaters coming into secondary care from primary care

CLINICAL RELEVANCE

Optometrists should look to take every opportunity to expand their knowledge, understanding and skills pertaining to vitreoretinal conditions.

BACKGROUND

Despite the existence of acute eye care schemes and the up-skilling of optometrists, many units are still noticing large numbers of poor-quality referrals with high false positive rates. The authors pondered whether these schemes are effective.

METHODS

At two different time points, a prospective analysis of patients took place, of all the flashing lights and floaters referrals coming into secondary care at the Royal Glamorgan Hospital, Wales, UK. The following data was captured: the exact source of the primary care referral, the diagnosis being queried, the secondary care diagnoses made and the secondary care management decisions. The accuracy of retinal break and Shafer's sign detection were also directly compared between primary care and secondary care using Cohen's Kappa Coefficient.

RESULTS

For the 2018 period, n = 51 patients were included. For the 2022-23 period n = 100 patients were included. The majority of referrals during both periods were from optometrists (>80%) via the WECS pathway. The most common diagnoses being queried were retinal breaks (~50%), followed by retinal detachments (~20%). Interestingly up to 20% of patients seen in secondary care were diagnosed as normal examinations and ~ 20%. Over 1/3 of patients were discharged after their first visit to the EEC. Statistically significant differences were found between the accuracy of retinal tear and Shafer's identification between the primary and secondary care settings.

CONCLUSION

A high number of false positive referrals are coming into secondary care from the WECS pathway and clear training and education needs have been identified.

What are the experiences of teleophthalmology in optometric referral pathways? A qualitative interview study with patients and clinicians

OBJECTIVE

Implementing teleophthalmology into the optometric referral pathway may ease the current pressures on hospital eye services caused by over-referrals from some optometrists. This study aimed to understand the practical implications of implementing teleophthalmology by analysing lived experiences and perceptions of teleophthalmology in the optometric referral pathway for suspected retinal conditions.

DESIGN

Qualitative in-depth interview study SETTING: Fourteen primary care optometry practices and four secondary care hospital eye services from four NHS Foundation Trusts across the UK.

PARTICIPANTS

We interviewed 41 participants: patients (17), optometrists (18), and ophthalmologists (6) who were involved in the HERMES study. Through thematic analysis, we collated and present their experiences of implementing teleophthalmology.

RESULTS

All participants interviewed were positive towards teleophthalmology as it could enable efficiencies in the referral pathway and improve feedback and communication between patients and healthcare professionals. Concerns included setup costs for optometrists and anxieties from patients about not seeing an ophthalmologist face to face. However, reducing unnecessary visits and increasing the availability of resources and capacity were seen as significant benefits.

CONCLUSIONS

Overall, we report positive experiences of implementing teleophthalmology into the optometric referral pathway for suspected retinal conditions. Successful implementation will require appropriate investment to set up and integrate new technology and remunerate services, and continued evaluation to ensure timely feedback to patients and between healthcare professionals is received.

TRIAL REGISTRATION NUMBER

ISRCTN18106677.

Systematic review and appraisal of quality, definitions and treatment recommendations of clinical guidelines for glaucoma suspects

BACKGROUND

To appraise the quality of clinical practice guidelines for glaucoma suspects, and to assess their consistency for how a 'glaucoma suspect' is defined and their recommendations for treatment initiation for such individuals.

METHODS

This study included all documents that self-identified as a 'guideline' and provided recommendation(s) for the clinical care of glaucoma suspects. The quality of eligible guidelines was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.

RESULTS

From 1196 records retrieved from comprehensive searches and two records manually included, 20 clinical practice guidelines were deemed eligible. Based on an appraisal using the AGREE II instrument, 16 (80%) guidelines had ≤2 domains with scores >66%. Overall, the lowest scoring domains were for applicability, editorial independence and stakeholder involvement. There was relatively poor agreement across the guidelines for what defines a 'glaucoma suspect' or 'primary open angle glaucoma [POAG] suspect', as well as the recommendations and criteria for treatment initiation in these populations. There was better agreement for the definition and recommendations for treatment initiation for 'primary angle closure suspects'.

CONCLUSIONS

There is substantial room to improve the methodological quality of most current international clinical guidelines for glaucoma suspects. Clinicians should consider this finding when using such guidelines to inform their care of glaucoma suspects. Substantial variation in the definition of a POAG suspect and recommendations for treatment initiation underscores important gaps in the current evidence for the accurate prediction of glaucoma development and treatment effectiveness in these individuals.

Glaucoma Agreement in New Zealand (GAINZ)

CLINICAL RELEVANCE

With an ageing population, ophthalmologists are becoming burdened with glaucoma management, and patient care can be delayed. Therefore, the use of optometrists in glaucoma management can help alleviate the burden.

BACKGROUND

The ageing population and subsequent rise of glaucoma prevalence are putting a strain on the public health system in New Zealand. Glaucoma collaborative care between optometrists and ophthalmologists has been gaining support with the aim to reduce this burden on ophthalmologists. There has been little investigation of the agreement in care and management of mild-to-moderate severity glaucoma patients by optometrists and ophthalmologists.

METHODS

One hundred and three glaucomatous eyes were used in a survey where clinical history and examination, intraocular pressures (IOPs), visual field testing and optical coherence tomography (OCT) imaging were evaluated for glaucoma progression and decision-making regarding subsequent management by four participants. Two participants were glaucoma-credentialled optometrists (Group 1), and the other two were glaucoma specialists (Group 2).

RESULTS

With respect to glaucoma progression, Spearman coefficients identified strong agreement between the two groups for IOP, visual fields and overall status and moderate agreement for OCT imaging. A confusion matrix was used to analyse management and found 80% ± 10% agreement between the two groups. Review periods gave an agreement of 55% ± 20% between the two groups.

CONCLUSION

There was strong agreement in the assessment of glaucoma progression between the two groups. The 80% level of agreement for subsequent management between the two groups is comparable to other published reports. These results provide some reassurance that a collaborative care system can perform safely and as intended.

Outcomes of newly referred patients with suspected angle closure: do we need to redefine the clinical pathways?

BACKGROUND/OBJECTIVES

To investigate outcomes of referrals for suspected angle closure and explore whether anterior segment optical coherence tomography (AS-OCT) can be used to tighten triaging criteria in a glaucoma virtual clinic.

SUBJECTS/METHODS

Retrospectively collected data. The first audit (04/2018-03/2019) identified referrals for suspected angle closure without other glaucoma-related findings (primary angle closure suspect (PACS) referrals). All patients underwent gonioscopy. The second audit (04-08/2019) identified patients with suspected angle closure in a virtual clinic. Management outcomes were assessed, using gonioscopy as reference standard. The outcomes of the second audit were re-audited after changing the triaging criterion from angle width <10° to iridotrabecular contact (ITC) in ≥1 quadrants on AS-OCT.

RESULTS

Out of 1754 glaucoma referrals (first audit), 24.6% (431/1754) were PACS referrals. Of these, only 10.7% (42/393) had an occludable angle on gonioscopy, with 97.6% (41/42) being PACS. Of these, 78% (32/41) underwent laser peripheral iridotomy. Out of 137 referrals in the virtual clinic (second audit), 66.4% (91/137) were triaged to the face-to-face clinic. Of these, 31.9% (29/91) were discharged. AS-OCT had positive and negative predictive value of 74.3% (95% confidence intervals (CI) 57.8-86.0) and 82.1% (95% CI 70.0-90.2%), respectively, in detecting ITC in ≥1 quadrants. In the re-audit 45.9% (45/98) of those with suspected angle closure were triaged for gonioscopy, with 24.4% (11/45) of them being discharged.

CONCLUSION

PACS referrals represent a substantial burden to hospital-based services and their accuracy is low. ITC in ≥1 quadrants on AS-OCT can be useful in triaging those who need further evaluation with gonioscopy.

Assessment of optometrists' referral accuracy and contributing factors: A review

PURPOSE

In the UK, ophthalmology has the highest number of outpatient appointments within the National Health Service. False-positive referrals from primary care are one of the main factors contributing to the oversubscription of hospital eye services (HESs). We reviewed the accuracy of referrals originating from primary care optometrists and contributing factors, such as condition type and years since registration.

RECENT FINDINGS

Of the 31 studies included in the review, 22 were retrospective analyses of referrals and appointments at the HES. Eight were prospective studies, and one used online clinical vignettes. Seven assessed the accuracy of referrals for all ocular conditions. The remaining studies focused on glaucoma (n = 11), cataracts (n = 7), emergency conditions (n = 4), neovascular age-related macular degeneration (n = 1) and paediatric binocular vision (n = 1). The diagnostic agreement for suspected emergency ocular conditions was the lowest, with only 21.1% of referrals considered to require urgent attention in one study. For glaucoma, the first-visit discharge rate was high (16.7%-48%). Optometrist referral accuracy was overall 18.6% higher than General Medical Practitioners'; however, the two mainly referred different ocular conditions. Female optometrists made more false-positive referrals than males (p = 0.008). The proportion of false positives decreased by 6.2% per year since registration (p < 0.001).

SUMMARY

There was significant variation in referral accuracy across different ocular conditions, partly due to differences when defining accurate referrals. Optometrists working in primary care are generally more limited in their resources than the HES. Thus, choosing the cautious option of referral when they are unsure could be in the patients' best interests. The possible effect of increased use of advanced imaging on referrals requires evaluation. Although interventions such as refinement schemes have been put in place, these vary across regions, and their approaches such as virtual referral triaging may reduce unnecessary HES face-to-face appointments and promote communication between primary and secondary care.

Burden of Glaucoma in the United Kingdom: A Multicenter Analysis of United Kingdom Glaucoma Services

OBJECTIVE

To determine the spectrum of glaucoma-associated health care resource utilization among outpatients attending National Health Service (NHS) hospital glaucoma clinics and the costs of managing glaucoma in this setting.

DESIGN

Retrospective observational cohort study using electronic medical record data.

SUBJECTS

Patients aged ≥ 18 years attending 5 NHS glaucoma clinics in the United Kingdom (2013‒2018) with ≥ 12 months of continuous electronic medical record data.

METHODS

Deidentified Medisoft Ophthalmology electronic medical record data (January 2013‒December 2018) from 43 742 eligible patients were categorized by year of clinic visit. Extracted information included patient demographics, glaucoma diagnoses, topical glaucoma medication prescription start/stop dates, types/numbers of glaucoma clinic visits, glaucoma investigations (visual acuity, intraocular pressure, visual field, and OCT), and glaucoma procedures received over 12 months after the first ("index") visit of the specified year. Direct glaucoma-related health care costs (clinic visits, investigations, procedures, and ongoing glaucoma medication initiated in the clinic) were estimated from event volumes and unit costs (UK national tariffs) and expressed from the direct-payer perspective.

MAIN OUTCOME MEASURES

Glaucoma diagnoses and topical glaucoma medication use at the index clinic visit; numbers of glaucoma clinic visits, investigations and procedures; and glaucoma-related health care costs over 12 months postindex.

RESULTS

For the 2016 cohort (n = 21 719), the estimated average total cost of NHS-provided glaucoma care over 12 months was £405 per patient (medical staff services £209, glaucoma investigations £126, glaucoma medication £40, glaucoma procedures £26). Among this cohort, 40.8% had ocular hypertension/suspected glaucoma, 70% had 0-to-mild visual field impairment, and 14% had undergone a glaucoma procedure. Over 12 months, patients received (mean) 2.0 glaucoma clinic visits and 1.5 visual field tests, and 7% underwent glaucoma procedure(s). Results were similar for the other years examined.

CONCLUSIONS

Cost estimates for managing patients with glaucoma in the UK are required for effective service planning. Appreciable proportions of patients managed in NHS glaucoma clinics may be considered at low risk of blindness (glaucoma suspects and those with ocular hypertension with mild visual field loss) and may be more appropriately managed with alternative, more affordable models of care.

A prospective study on effectiveness of elevated intraocular pressure as a criterion for glaucoma referrals by optometric practitioners in Sweden

PURPOSE

To evaluate the outcome of referrals for suspected glaucoma based on elevated intraocular pressure (IOP) made by optometric practitioners in Sweden.

METHODS

This prospective study included 95 individuals referred to the Skåne University Hospital Malmö, Sweden, during 2019, by optometric practitioners, based on elevated IOP. Positive outcome was defined as a diagnosis of glaucoma, or a diagnosis of suspected glaucoma. Referral accuracy was analysed. Positive predictive values (PPV) of different hypothetical IOP and age thresholds were calculated.

RESULTS

In 34% (95% CI: 24-43%) of the referrals, no eye disease was found. Intraocular pressure (IOP) was the only referral criterion in 77% (73/95). The PPV was 35% (95% CI: 25-45%) for all referrals, 27% (95% CI: 16-38%) for IOP-only referrals and 59% (95% CI: 36-82%) for referrals including additional findings. In IOP-only referrals, no definite diagnosis of glaucoma was made in any patients <45 years of age. Applying a theoretical age limit of ≥45 years with a hypothetical IOP limit of ≥25 mmHg in patients 45-69 years and of ≥22 mmHg in patients ≥70 years increased the PPV to 42% (95% CI: 27-57%). IOP-only referrals would have been reduced by 27% without missing any glaucoma cases.

CONCLUSION

The overall predictive value of the referrals was poor. Glaucoma resources would have been used more effectively by increasing the required age for IOP-only referrals to ≥45 years in combination with different IOP thresholds for certain age groups.

Ophthalmology Going Greener: A Narrative Review

The combined effects of fossil fuel combustion, mass agricultural production and deforestation, industrialisation and the evolution of modern transport systems have resulted in high levels of carbon emissions and accumulation of greenhouse gases, causing profound climate change and ozone layer depletion. The consequential depletion of Earth's natural ecosystems and biodiversity is not only a devastating loss but a threat to human health. Sustainability-the ability to continue activities indefinitely-underpins the principal solutions to these problems. Globally, the healthcare sector is a major contributor to carbon emissions, with waste production and transport systems being amongst the highest contributing factors. The aim of this review is to explore modalities by which the healthcare sector, particularly ophthalmology, can reduce carbon emissions, related costs and overall environmental impact, whilst maintaining a high standard of patient care.

Referrals from community optometrists to the hospital eye service in Scotland and England

Objectives

This audit assesses communication between community optometrists (COs) and hospital eye service (HES) in Scotland and England.

Methods

Optometric referrals and replies were extracted from six practices in Scotland and England. If no reply was found, replies/records were copied from HES records. De-identified referrals, replies and records were audited against established standards, evaluating whether referrals were necessary, accurate and directed to the appropriate professional. The referral rate (RR) and referral reply rate (RRR) were calculated.

Results

From 905 de-identified referrals, RR ranged from 2.6 to 8.7%. From COs’ perspective, the proportion of referrals for which they received replies ranged from 37 to 84% (Scotland) and 26 to 49% (England). A total of 88–96% of referrals (Scotland) and 63–76% (England) were seen in the HES. Adjusting for cases when it is reasonable to expect replies, RRR becomes 45–92% (Scotland) and 38–62% (England) with RRR significantly greater in Scotland (P = 0.015). Replies were copied to patients in 0–21% of cases. Referrals were to the appropriate service and judged necessary in ≥90% of cases in both jurisdictions. Accuracy of referral ranged from 89 to 97% (Scotland) and 81 to 98% (England). The reply addressed the reason for referral in 94–100% of cases (Scotland) and 93–97% (England) and was meaningful in 95–100% (Scotland) and 94–99% (England).

Conclusions

Despite the interdisciplinary joint statement on sharing patient information, this audit highlights variable standard of referrals and deficits in replies to the referring COs, with one exception in Scotland. Replies from HES to COs are important for patient care, benefitting patients and clinicians and minimising unnecessary HES appointments.

Referrals from community optometrists to the hospital eye service in England

PURPOSE

In the UK, most referrals to the hospital eye service (HES) originate from community optometrists (CO). This audit investigates the quality of referrals, replies, and communication between CO and the HES.

METHODS

Optometric referrals and replies were extracted from three practices in England. If no reply letter was found, the records were searched at each local HES unit, and additional replies or records copied. De-identified referrals, replies and records were audited by a panel against established standards to evaluate whether the referrals were necessary, accurate and directed to the appropriate professional. The referral rate (RR) and referral reply rate (RRR) were calculated.

RESULTS

A total of 459 de-identified referrals were extracted. The RR ranged from 3.6%-8.7%. The proportion of referred patients who were seen in the HES unit was 63%-76%. From the CO perspective, the proportion of referrals for which they received replies ranged from 26%-49%. Adjusting the number of referrals for cases when it would be reasonable to expect an HES reply, RRR becomes 38%-62%. Patients received a copy of the reply in 3%-21% of cases. Referrals were made to the appropriate service in over 95% of cases, were judged necessary in 93%-97% and were accurate in 81%-98% of cases. The referral reply addressed the reason for the referral in 93%-97% and was meaningful in 94%-99% of cases. The most common conditions referred were glaucoma, cataract, anterior segment lesions, and neurological/ocular motor anomalies. The CO/HES dyad (pairing) in the area with the lowest average household income had the highest RR.

CONCLUSIONS

In contrast with the Royal College of Ophthalmologists/College of Optometrists joint statement on sharing patient information, CO referrals often do not elicit a reply to the referring CO. Replies from the HES to COs are important for patient care, benefitting patients and clinicians, and minimising unnecessary HES appointments.

The role of the disc damage likelihood scale in glaucoma detection by community optometrists

PURPOSE

Recent guidelines recommend disc damage likelihood scale (DDLS) is recorded for all referrals of suspected glaucoma from community optometrists to hospital eye services (HES) in Scotland. This study aimed to determine whether lower DDLS grades were associated with higher rates of discharge at the first visit to HES.

METHODS

A retrospective analysis of 618 consecutive new referrals from community optometrists to a university hospital glaucoma service. 65 (10.5%) included DDLS graded by the community optometrist. A comprehensive eye examination and optical coherence tomography (OCT) was performed in the hospital glaucoma clinic and first visit discharge rate (FVDR) for different grades of DDLS compared. The relationship between DDLS and retinal nerve fibre layer (RNFL) thickness on OCT was also examined.

RESULTS

The FVDR for patients with DDLS recorded in the referral was 27.7% (18 of 65) compared to 25% (138 of 553) in those without DDLS (p = 0.631). The FVDR was 50% for those with a DDLS of 3 in the worse eye, decreasing to 32% and 21% for DDLS grades of 4 and 5 respectively. No patient with a DDLS ≥ 6 was discharged at the first visit and none with a DDLS < 4 (the cut off for consideration of referral in Scottish guidelines) were found to have glaucoma. There was a significant but weak inverse relationship between DDLS and RNFL thickness. The strongest relationship was with average RNFL thickness (r = -0.378, p < 0.01) followed by superotemporal (r = -0.359, p < 0.01) and inferotemporal (r = -0.353, p < 0.01) RNFL thickness.

CONCLUSIONS

In patients referred to HES with DDLS information included, lower DDLS grading was associated with higher odds of being discharged at the first visit. DDLS grading by community optometrists had a poor correlation with RNFL thickness measured using OCT.

Using an open-source tablet perimeter (Eyecatcher) as a rapid triage measure for glaucoma clinic waiting areas

Background

Glaucoma services are under unprecedented strain. The UK Healthcare Safety Investigation Branch recently called for new ways to identify glaucoma patients most at risk of developing sight loss, and of filtering-out false-positive referrals. Here, we evaluate the feasibility of one such technology, Eyecatcher: a free, tablet-based ‘triage’ perimeter, designed to be used unsupervised in clinic waiting areas. Eyecatcher does not require a button or headrest: patients are simply required to look at fixed-luminance dots as they appear.

Methods

Seventy-seven people were tested twice using Eyecatcher (one eye only) while waiting for a routine appointment in a UK glaucoma clinic. The sample included individuals with an established diagnosis of glaucoma, and false-positive new referrals (no visual field or optic nerve abnormalities). No attempts were made to control the testing environment. Patients wore their own glasses and received minimal task instruction.

Results

Eyecatcher was fast (median: 2.5 min), produced results in good agreement with standard automated perimetry (SAP), and was rated as more enjoyable, less tiring and easier to perform than SAP (all p<0.001). It exhibited good separation (area under receiver operating characteristic=0.97) between eyes with advanced field loss (mean deviation (MD) < −6 dB) and those within normal limits (MD > −2 dB). And it was able to flag two thirds of false-positive referrals as functionally normal. However, eight people (10%) failed to complete the test twice, and reasons for this limitation are discussed.

Conclusions

Tablet-based eye-movement perimetry could potentially provide a pragmatic way of triaging busy glaucoma clinics (ie, flagging high-risk patients and possible false-positive referrals).

Delayed attendance at routine eye examinations is associated with increased probability of general practitioner referral: a record linkage study in Northern Ireland

PURPOSE

To investigate relationships between health and socio-economic status with delayed attendance at routine eye examinations and risk of subsequent general practitioner (GP) referral in Northern Ireland.

METHODS

We constructed a cohort of 132 046 community dwelling individuals aged ≥60 years, drawing contextual information from the 2011 Northern Ireland Census. Using linked administrative records of routine eye examinations between 2009 and 2014, we calculated 311 999 examination intervals. Multinomial models were used to estimate associations between contextual factors and examination interval (classified into three groups: early recall, on-time, delayed attendance). Associations between examination interval and referral risk were estimated using logistic regression.

RESULTS

Delayed attendance was recorded for 129 857 (41.6%) examination intervals, 53 759 (17.2%) delayed by ≥6 months. Female sex, poor general or mental health were each associated with delay, as were longer distances to optometry services among those aged ≥70 years (longest vs shortest: Relative Risk Ratio = 1.21 [1.14, 1.28]). Low income and residence in social housing were associated with reduced delay risk. There were 3347 (3.5%) and 11 401 (5.3%) GP referrals in the 60-69 and ≥70 years age groups respectively. Delayed attendance was associated with increased referral risk in both groups (Odds Ratios: 60-69 years = 1.30 [1.04, 1.61]; ≥70 years = 1.07 [1.01, 1.13]).

CONCLUSIONS

Poor health and longer distances to optometry services were associated with delayed attendance at routine eye examinations but low income was not. Delayed attendance was associated with increased GP referral risk, indicative of missed opportunities to detect potentially serious eye conditions.

Impact of referral refinement on management of glaucoma suspects in Australia

BACKGROUND

In ageing populations, the prevalence of chronic diseases such as glaucoma is projected to increase, placing additional demands on limited health-care resources. In the UK, the demand for secondary care in hospital eye clinics was inflated by high rates of false positive glaucoma referrals. Collaborative care models incorporating referral refinement, whereby glaucoma suspect referrals are triaged by suitably trained optometrists through further testing, can potentially reduce false positive referrals. This study examined the impact of a referral refinement model on the accuracy of glaucoma referrals in Australia.

METHODS

Optometrist-initiated glaucoma suspect referrals to the Glaucoma Management Clinic (Sydney, Australia) were prospectively recruited. Glaucoma suspect referrals arising from two pathways were eligible for inclusion, either directly from a community optometrist (standard care) or following comprehensive assessment at the Centre for Eye Health (referral refinement). Main outcome measures were the positive predictive value and false positive rate of referrals. The impact of referral letter content on management outcomes was also investigated.

RESULTS

Of 464 referrals received between March 2015 and June 2018, 252 were for treatment of naïve glaucoma suspects and eligible for inclusion. Following ophthalmological assessment, 45.6 per cent (n = 115/252) were prescribed treatment for open angle glaucoma or ocular hypertension. Positive predictive value of community optometry referrals was 33.8 per cent (n = 25/74) and 50.6 per cent (n = 90/178) following referral refinement. The first visit discharge (false positive) rate was 26 per cent (n = 19/74) for community referrals compared to four per cent (n = 8/178) with referral refinement. Positive predictive value increased with the number of abnormal clinical examination findings associated with referral (χ² test, p < 0.0001). The number of abnormal findings reported in referrals was significantly higher with referral refinement compared to without (n = 1.9 versus 1.5, t-test, p < 0.0001).

CONCLUSION

Referral refinement can improve the diagnostic accuracy of optometry-initiated referrals for glaucoma suspects in Australia, thereby decreasing unnecessary referrals to hospital and other secondary clinics.

Impact of optical coherence tomography on diagnostic decision-making by UK community optometrists: a clinical vignette study

Purpose

In recent years, there has been widespread investment in imaging technologies by community optometrists in the UK, most notably optical coherence tomography (OCT). The aim of the current study was to determine the value of OCT in the diagnosis of posterior segment diseases in a representative sample of community optometrists using a clinical vignette methodology.

Methods

A group of community optometrists (n = 50) initially completed a standardised training package on OCT interpretation followed by a computer‐based assessment featuring 52 clinical vignettes, containing images of healthy (n = 8) or glaucomatous (n = 18) discs or healthy (n = 8) or diseased (n = 18) fundi. Each vignette featured either a single fundus/disc photographic image, or a combination of a fundus/disc image with the corresponding OCT scan. An expert panel confirmed that the fundus images presented alone and those in combination with OCT data were of a similar level of difficulty and that the cases were typical of those seen in primary care. For each case, the optometrist selected their diagnosis from a pull‐down list and reported their confidence in their decision using a 10‐point Likert scale. Pairwise comparisons of the fundus image alone and fundus image/OCT combination were made for both diagnostic performance and confidence.

Results

The mean percentage of correct diagnoses using fundus imaging alone was 62% (95% CI 59–64%) and for the combination of fundus image/OCT was 80% (95% CI 77–82%). The mean false negative rate with fundus alone was 27% reducing to 13% with the OCT combination. Median confidence scores for fundus imaging alone was 8.0 (IQR 7.0–8.0) and 8.3 (IQR 8.0–9.0) for the combination. Improvements in performance and confidence were statistically significant (p < 0.001).

Conclusion

The results from this vignette study suggests that OCT improves optometrists’ diagnostic performance compared to fundus observation alone. These initial results suggest that OCT provides valuable additional data that could augment case‐finding for glaucoma and retinal disease; however, further research is needed to assess its diagnostic performance in a routine clinical practice setting.

Feeling the pressure: a cross-sectional study exploring feasibility of a healthcare Pop-Up for intraocular pressure measurements in shopping centres in England

OBJECTIVES

To test the hypothesis that a shopping centre Pop-Up health check combining an intraocular pressure (IOP) check with a general health check (blood pressure (BP)) is more readily accepted by the general public than an IOP check only. We investigate public awareness of IOP compared with BP and the feasibility of measuring IOP in large numbers in a Pop-Up.

DESIGN

A cross-sectional study using a tailor-made healthcare Pop-Up.

SETTING

The 'Feeling the Pressure' Pop-Up was sited in eight regionally-different shopping centres in England.

PARTICIPANTS

Adult members of the public in shopping centres.

METHODS

On one day we measured IOP only and on another measured BP and IOP. IOP was measured by Icare IC100 tonometer (Helsinki, Finland). Potential participants were asked about their awareness of IOP and BP and when they last visited their optometrist.

RESULTS

More people attended the combined BP + IOP days (461; 60%; 95% CI 56% to 64%) than IOP-only days (307; 40%, 95% CI 37% to 43%) over 16 days of testing. We recorded IOP in 652 participants (median (IQR) age and IOP of 54 (42 to 68) years and 13 (11 to 15) mm Hg, respectively). Fewer people reported awareness about IOP (19%, 95% CI 16% to 23%) compared with BP (71%, 95% CI 66% to 75%). Of 768 participants, 60 (8%) reported no previous optometric eye examination and 185 (24%) reported >2 years since their most recent examination.

CONCLUSIONS

Measuring IOP in large numbers of the public via a shopping centre Pop-Up is feasible. Public engagement was greater when a BP check was offered alongside an IOP check, suggesting unfamiliar health checks can be promoted by aligning them with a more familiar check. Our findings hint at strategies for public health schemes that engage the public with their eye health.

Care pathways for glaucoma detection and monitoring in the UK

Glaucoma presents considerable challenges in providing clinically and cost-effective care pathways. While UK population screening is not seen as justifiable, arrangements for case finding have historically been considered relatively ineffective. Detection challenges include an undetected disease burden, whether from populations failing to access services or difficulties in delivering effective case-finding strategies, and a high false positive rate from referrals via traditional case finding pathways. The enhanced General Ophthalmic Service (GOS) in Scotland and locally commissioned glaucoma referral filtering services (GRFS) elsewhere have undoubtedly reduced false positive referrals, and there is emerging evidence of effectiveness of these pathways. At the same time, it is recognised that implementing GRFS does not intrinsically reduce the burden of undetected glaucoma and late presentation, and obvious challenges remain. In terms of diagnosis and monitoring, considerable growth in capacity remains essential, and non-medical health care professional (HCP) co-management and virtual clinics continue to be important solutions in offering requisite capacity. National guidelines, commissioning recommendations, and the Common Clinical Competency Framework have clarified requirements for such services, including recommendations on training and accreditation of HCPs. At the same time, the nature of consultant-delivered care and expectations on the glaucoma specialist's role has evolved alongside these developments. Despite progress in recent decades, given projected capacity requirements, further care pathways innovations appear mandated. While the timeline for implementing potential artificial intelligence innovations in streamlining care pathways is far from established, the glaucoma burden presents an expectation that such developments will need to be at the vanguard of future developments.

Impact of the Manchester Glaucoma Enhanced Referral Scheme on NHS costs

Objectives

Glaucoma filtering schemes such as the Manchester Glaucoma Enhanced Referral Scheme (GERS) aim to reduce the number of false positive cases referred to Hospital Eye Services. Such schemes can also have wider system benefits, as they may reduce waiting times for other patients. However, previous studies of the cost consequences and wider system benefits of glaucoma filtering schemes are inconclusive. We investigate the cost consequences of the Manchester GERS.

Design

Observational study.

Methods

A cost analysis from the perspective of the National Health Service (NHS) was conducted using audit data from the Manchester GERS.

Results

2405 patients passed through the Manchester GERS from April 2013 to November 2016. 53.3% were not referred on to Manchester Royal Eye Hospital (MREH). Assuming an average of 2.3 outpatient visits to MREH were avoided for each filtered patient, the scheme saved the NHS approximately £2.76 per patient passing through the scheme.

Conclusion

Our results indicate that glaucoma filtering schemes have the potential to reduce false positive referrals and costs to the NHS.

Severity of Visual Field Loss at First Presentation to Glaucoma Clinics in England and Tanzania

Purpose: To compare severity of visual field (VF) loss at first presentation in glaucoma clinics in England and Tanzania.Methods: Large archives of VF records from automated perimetry were used to retrospectively examine vision loss at first presentation in glaucoma clinics in Tanzania (N = 1,502) and England (N = 9,264). Mean deviation (MD) of the worse eye at the first hospital visit was used as an estimate of detectable VF loss severity.Results: In Tanzania, 44.7% {CI_95%: 42.2, 47.2} of patients presented with severe VF loss (< -20 dB), versus 4.6% {4.1, 5.0} in England. If we consider late presentation to also include cases of advanced loss (-12.01 dB to -20 dB), then the proportion of patients presenting late was 58.1% {55.6, 60.6} and 14.0% {13.3, 14.7}, respectively. The proportion of late presentations was greater in Tanzania at all ages, but the difference was particularly pronounced among working-age adults, with 50.3% {46.9, 53.7} of 18-65-year-olds presenting with advanced or severe VF loss, versus 10.2% {9.3, 11.3} in England. In both countries, men were more likely to present late than women.Conclusions: Late presentation of glaucoma is a problem in England, and an even greater challenge in Tanzania. Possible solutions are discussed, including increased community eye-care, and a more proactive approach to case finding through the use of disruptive new technologies, such as low-cost, portable diagnostic aids.

A collaborative care pathway for patients with suspected angle closure glaucoma spectrum disease

BACKGROUND

Currently, no specific collaborative care pathway exists that distinguishes open angle glaucoma from narrow angle or angle closure disease. This study evaluates a newly developed referral and collaborative care pathway specifically for patients with angle closure spectrum disease.

METHODS

The medical records of consecutive patients referred to the Centre for Eye Health for glaucoma assessment were examined, six months before (Pre Suite) and after (Post Suite) the introduction of a novel referral pathway for anterior chamber angle assessment (Angle Suite). Patient demographic and clinical data, the referral letter and practitioner characteristics were extracted.

RESULTS

Angle Suite (n = 77) patients had an appointment much sooner compared to Pre (n = 383) and Post Suite (n = 425) patients (p < 0.0001). Following the introduction of Angle Suites, there was a reduction of incidental angle closure disease found in routine, non-angle closure glaucoma assessment. Onward referral was required by 36.4 per cent of patients referred for suspected angle closure disease, while the rest could be discharged back into the community (13.0 per cent) or reviewed at the Centre for Eye Health (50.6 per cent). Multinomial logistic regression found that the presence of an angle description in the referral letter improved the true positive rate for angle closure disease (p < 0.0001).

CONCLUSIONS

The clinical pathway may reduce the number of incidental angle closure patients and improved the timeliness of appropriate clinical care delivered to a subset of patients who may benefit from prompt medical attention. This pathway provides an opportunity for appropriately staffed and equipped collaborative care clinics to reduce the burden on tertiary level ophthalmic facilities.

Accuracy of detection of patients with narrow angles by community optometrists in Scotland

AIM

To examine the accuracy of referrals by community optometrists for suspected primary angle closure, including primary angle closure suspects, primary angle closure and primary angle closure glaucoma.

METHODS

A retrospective review of 769 consecutive patients referred by community optometrists to the glaucoma clinic at a university hospital in Scotland. Ninety-five of 715 eligible subjects (13%) were referred due to suspected angle closure. All subjects had a comprehensive eye examination in the glaucoma clinic, including gonioscopy, with angle closure defined according to the International Society of Geographical and Epidemiological Ophthalmology classification as iridotrabecular contact over at least 270 degrees.

RESULTS

Fifty-nine of 95 subjects referred due to suspected angle closure were confirmed to have an occludable angle, while 36 of 95 (38%) had open angles (positive predictive value = 62%). Of 620 patients referred to the glaucoma clinic for reasons other than narrow angles, 601 (97%) had open angles on gonioscopy and 19 (3%) had narrow angles. Using the 620 patients referred with 'open angles' as a control group, sensitivity was estimated as 76% and specificity 94%. Eleven of 95 (12%) patients referred for possible angle closure were discharged at the first visit compared to 156 of 620 (25%) referred to the glaucoma clinic for other reasons (p = 0.003). In a multivariable model, suspect angle closure detected by the optometrist (OR = 56.0, 95% CI 35.2-89.2, p < 0.001) and female gender (OR = 1.9, 95% CI 1.2-3.1, p = 0.008) were associated with increased odds of angle closure on gonioscopy.

CONCLUSION

Community optometrists had good ability to detect eyes at risk of angle closure. There was also greater accuracy of referrals for suspected angle closure than for other glaucoma referrals.

Clinical effectiveness of the Manchester Glaucoma Enhanced Referral Scheme

Background

Glaucoma referral filtering schemes have operated in the UK for many years. However, there is a paucity of data on the false-negative (FN) rate. This study evaluated the clinical effectiveness of the Manchester Glaucoma Enhanced Referral Scheme (GERS), estimating both the false-positive (FP) and FN rates.

Method

Outcome data were collected for patients newly referred through GERS and assessed in ‘usual-care’ clinics to determine the FP rate (referred patients subsequently discharged at their first visit). For the FN rate, glaucoma suspects deemed not requiring referral following GERS assessment were invited to attend for a ‘reference standard’ examination including all elements of assessment recommended by National Institute for Health and Care Excellence (NICE) by a glaucoma specialist optometrist. A separate 33 cases comprising randomly selected referred and non-referred cases were reviewed independently by two glaucoma specialist consultant ophthalmologists to validate the reference standard assessment.

Results

1404 patients were evaluated in GERS during the study period; 651 (46.3%) were referred to the Hospital Eye Service (HES) and 753 (53.6%) were discharged. The FP rate in 307 assessable patients referred to the HES was 15.5%. This study reviewed 131 (17.4%) of those patients not referred to the HES through the GERS scheme; 117 (89.3%) were confirmed as not requiring hospital follow-up; 14 (10.7%) required follow-up, including 5 (3.8%) offered treatment. Only one patient (0.8%) in this sample met the GERS referral criteria and was not referred (true FN). There were no cases of missed glaucoma or non-glaucomatous pathology identified within our sample.

Conclusion

The Manchester GERS is an effective glaucoma filtering scheme with a low FP and FN rate.

Expanding the traditional role of optometry: Current practice patterns and attitudes to enhanced glaucoma services in Ireland

PURPOSE

To investigate current diagnostic equipment availability and usage for glaucoma case-finding within community optometric practice, and to explore optometrists' attitudes towards an enhanced scope of clinical practice.

METHODS

An anonymous survey was developed, validated, and distributed to all optometrists in Ireland.

RESULTS

199 optometrists (27% of registrants) responded to the survey. 87% had access to the traditional triad of tests necessary to conduct adequate glaucoma case finding. Standard automated perimetry was the most commonly absent (13%) of the three essential screening tests. 64% of respondents indicated that monocular direct ophthalmoscopy was their first choice technique for fundus examination. 47% of respondents had access to contact applanation tonometry, though just 14% used it as first choice during routine eye examinations. Among the 73 participants with access to both contact and non-contact tonometry (NCT), 80.8%, used NCT preferentially. The significant majority (98%) indicated an interest in enhanced glaucoma services with 57% agreeing that postgraduate training was an essential prerequisite to any increase in scope of practice.

CONCLUSION

Irish optometrists are well equipped with the traditional tests used in glaucoma detection. However, implementation of enhanced referral schemes or glaucoma monitoring or management services would require equipment upgrades and associated training in at least half of the surveyed practices. There is strong interest in furthering optometric professional development and expanding the traditional role boundaries of optometrists, incorporating further education as an essential prerequisite to an enhanced scope of practice.

The relationship between unwarranted variation in optometric referrals and time since qualification

PURPOSE

To investigate variation in optometric referral decision-making and the influence of experience and continuing education and training (CET).

METHODS

To gain insight into unwarranted variation in referral activity in the United Kingdom (UK): (1) triage data were audited to investigate source of referral, provisional diagnosis, and outcome; (2) an online system was developed to present two sets of 10 vignettes, designed to avoid prompting answers. Participating optometrists completed 10 pre-CET vignettes, recording their tests and management decisions. The main group of participants chose whatever CET they wished over a 6-month period and then completed another 10 post-CET vignettes. A second group of newly-qualified optometrists completed the vignettes before and after a CET course intervention, followed by a third group of pre-registered optometrists with an intervention of 6-months experience of their pre-registration year.

RESULTS

The audit identified 1951 optometric referrals and 158 optometrists (211 referrals were from general medical practitioners), with 122 of the 158 optometrists making fewer than ten referrals. Two newly-qualified optometrists generated 12.5% of the total referrals in the audit (N = 2162). Many suspect glaucoma referrals were based on a single suspect measurement resulting in a high discharge rate after community review, as did referrals for certain fundus-related appearances for which no treatment was indicated. The intervention of gaining CET points appeared to have no significant impact (p = 0.37) on referral decision-making, although this part of the study was underpowered. Self-selection bias was confirmed in the main group. When the main group and newly-qualified practitioners were compared, the number of referrals was negatively associated with time since qualification (p = 0.005). When all 20 referral decisions were compared, all optometrists referring more than 10 vignette patients came from a group of newly-qualified practitioners up to 2 years post-qualification. Pre-registered optometrists generally referred more appropriately than newly-qualified. Upon qualification, there was a significant increase in the number of sight tests undertaken per day (p = <0.0005).

CONCLUSIONS

Gaining CET points alone is unlikely to significantly improve referral decision-making. Mentoring and targeted CET for the newly-qualified up to 2 years post-qualification should be considered. Ophthalmology replies to the referring newly-qualified optometrist are vital for moderating future referrals and developing clinical confidence.

Difference in intraocular pressure measurements between non-contact tonometry and Goldmann applanation tonometry and the role of central corneal thickness in affecting glaucoma referrals

BACKGROUND

Patients at glaucoma risk are commonly identified by optometrists and subsequently referred to glaucoma specialists. Optometrists mainly use non-contact tonometry (NCT) for intraocular pressure (IOP) measurement.

AIMS

To investigate the role of differences in IOP measurement between NCT and Goldmann applanation tonometry (GAT) and the effect of central corneal thickness (CCT) on these differences in optometrist referrals METHODS: Details of the initial clinical visit of patients referred with IOP > 21 mmHg in either eye as measured by NCT to a consultant glaucoma specialist were retrospectively reviewed. Demographic and referral data, IOP, CCT, and glaucoma diagnosis were obtained. The main outcome measure was the IOP measurement differences between NCT and GAT.

RESULTS

Of the 98 patients referred, only 23% had IOP > 21 mmHg when measured by GAT. NCT (Nidek NT400, Reichert Puff, Pulsair Easy Eye) measured the IOP greater than GAT by a mean of 5.8 mmHg (NCT 24.1 ± 3.5, GAT 18.3 ± 3.0). The effect of CCT on IOP measurement was less for GAT (R² 0.034, p = 0.067) than for NCT (R² 0.088, p = 0.003). The NCT/GAT IOP differences increased with increasing CCT (R² 0.166, p < 0.0001). The NCT/GAT differences decreased with patient age (R² 0.048, p = 0.03). Patients were classified as normal 67% (66/98), ocular hypertension 11% (11/98), glaucoma suspect 14% (14/98), and glaucoma 7% (7/98).

CONCLUSIONS

The difference in IOP measurement between NCT and GAT leads to a possible increase in glaucoma referrals, particularly in patients with thicker corneas. Repeat IOP using GAT and CCT measurement would help in triaging referrals.

Glaucoma referral refinement in Ireland: managing the sensitivity-specificity paradox in optometric practice

PURPOSE

Glaucoma referral refinement (GRR) has proven a successful demand management strategy for glaucoma suspect cases in the United Kingdom (UK). A GRR clinic was established in Dublin, Ireland to investigate the clinical viability of this pathway outside the UK's National Health Service (NHS) structures, and away from the influence of National Institute for Clinical Excellence (NICE) guidance.

METHODS

Glaucoma suspect patients were recruited into the scheme following referral from community optometrists in the greater Dublin area. The GRR exam protocol was designed in consultation with the participating ophthalmology department. The refinement scheme optometrist, trained through apprenticeship style experience at a hospital outpatient clinic, made a tentative management decision after carrying out the GRR exam. The final management decision was made in a 'virtual clinic' by a glaucoma specialist consultant ophthalmologist.

RESULTS

Two hundred and twenty-five glaucoma suspect patients were seen in the scheme. After their first GRR visit, 28% were discharged back to their own optometrist, 42% were monitored in the GRR clinic, and 30% were referred to ophthalmology. After this monitoring cohort were further assessed, a total of 38% of the patients seen within the scheme required referral to ophthalmology. Sixteen percent of the total participant group (n = 225) were lost to follow up. Cohen's κ was used to determine the level of agreement between the scheme optometrist and ophthalmologist. There was substantial agreement, with κ = 0.63 for the first visit management decisions (n = 225). Agreement increased for subsequent monitoring visits with κ = 0.85 for second visits (n = 65), and κ = 0.69 for all management decisions within the scheme (n = 301). We received management outcomes for 44 of the 86 patients referred to ophthalmology. Of these 44, 57% received medical treatment for glaucoma, 34% were monitored without treatment, 2% were discharged, and 7% had comorbidities that were assessed and managed.

CONCLUSION

Of the patients seen within the scheme, 62% did not require referral onward to ophthalmology, thus releasing the significant majority of hospital clinic slots that would previously have been required to examine such patients. The high level of inter-professional decision agreement likely reflects the benefits of pre-scheme apprenticeship style training and ongoing hospital clinic participation by the scheme optometrist. The rate of loss to follow up compares favourably with ophthalmology led, hospital based, glaucoma clinics. Nevertheless, the losses indicate that patient education remains a key priority for future planning.

Prospective study of glaucoma referrals across Europe: are we using resources wisely?

BACKGROUND

To investigate the outcomes of glaucoma referrals across different European countries.

METHODS

250 patients newly referred to tertiary referral glaucoma specialist practices in the UK, Hungary, Slovenia, Italy and Greece were prospectively enrolled (50 consecutive patients per centre). Referral accuracy and predictive value of referral criteria for an intervention or further monitoring (positive predictive value) were analysed.

RESULTS

Same-day discharges occurred in 43% (95% CI 39% to 75%) (12/28) of optometrist-initiated referrals (UK only), 37% (95% CI 30% to 45%) (59/158) of ophthalmologist-initiated referrals (all centres) and 54% (95% CI 40% to 68%) (26/48) of self-referrals (Hungary, Italy and Greece). The percentages from all referral sources were 46% (95% CI 32% to 60%) in the UK, 56% (95% CI 44% to 70%) in Hungary, 30% (95% CI 17% to 43%) in Slovenia, 22% (95% CI 11% to 34%) in Italy and 60% (95% CI 46% to 74%) in Greece (p<0.001). Overall, the referring criterion was confirmed in 54% (95% CI 45% to 63%) (64/119) for intraocular pressure (IOP) >21 mm Hg, 56% (95% CI 43% to 69%) (33/59) for a suspicious optic disc and 61% (95% CI 45% to 77%) (22/36) for a suspicious visual field, with large between-country differences (p<0.05 for all comparisons). Of all referrals, 32% (95% CI 26% to 37%) were initiated on the basis of IOP >21 mm Hg only. By combining the IOP criterion with any other referring criterion, the positive predictive value increased from 56% (95% CI 45% to 67%) to at least 89% (95% CI 68% to 100%). In the UK, a hypothetical IOP threshold of >26 mm Hg, as a requirement for IOP-only referrals, would reduce IOP-only referrals by 44%, while not missing any definite glaucoma cases.

CONCLUSION

The accuracy of referrals was poor in the UK and the other countries. Requiring a combination of criteria and raising the IOP threshold for IOP-only referrals are needed to cut waste in clinical care.

A Mixed-Methods Evaluation of a Community-Based Glaucoma Check Service in Hackney, London, UK

PURPOSE

To evaluate the uptake, feasibility and acceptability of a general practice-based optometrist-led glaucoma check service. The service targeted people of black Caribbean and black African descent aged 40-65 years, resident in Hackney, London, United Kingdom.

METHODS

The study used a mixed-method design, including analysis of service data, prospective audit of secondary care referrals patient survey, cost-consequence analysis, and interviews with staff involved in developing and implementing the service.

RESULTS

A total of 3040 patients were invited to undergo the free check; 595 (19.6%) booked an appointment and 461 (15.2%) attended. Overall, 31 patients (6.8%) were referred to secondary care, of whom 22 attended and were assessed for glaucoma. Four were diagnosed with glaucoma and eight with suspected glaucoma, i.e. 2.6% of patients who underwent the check. The cost per patient identified with suspected or confirmed glaucoma was £9,013. Staff who were interviewed suggested that patients who attended might be those who routinely attended optometrist appointments, however only 62.4% of survey respondents reported having had an eye examination in the previous two years, and 11.4% of women and 16.0% of men reported never having had an eye examination.

CONCLUSION

This study represents one possible configuration for a glaucoma case-finding service, and it contributes to a wider debate about whether screening, targeted or otherwise, should be offered in the UK. Our findings suggest that general practice is an acceptable setting and that such a service may reach some people not previously engaged with primary eye care services.

Undetected angle closure in patients with a diagnosis of open-angle glaucoma

OBJECTIVE

The aim of this study was to identify the proportion of patients referred to a tertiary glaucoma centre with a diagnosis of open-angle glaucoma (OAG) who were found to have angle closure glaucoma.

DESIGN

Retrospective chart review.

METHODS

Consecutive new patients referred for glaucoma management to a tertiary centre between July 2010 and December 2011 were reviewed. Patients whose referrals for glaucoma assessment specified angle status as "open" were included. The data collected included glaucoma specialist's angle assessment, diagnosis, and glaucoma severity. The status of those with 180 degrees or more Shaffer angle grading of 0 was classified as "closed."

RESULTS

From 1234 glaucoma referrals, 179 cases were specified to have a diagnosis of OAG or when angles were known to be open. Of these, 16 (8.9%) were found on examination by the glaucoma specialist to have angle closure. Pseudoexfoliation was present in 4 of 16 patients (25%) in the missed angle-closure glaucoma (ACG) group and 22 of 108 patients (13.5%) in the remaining OAG group. There was no difference found in demographic or ocular biometric parameters between those with confirmed OAG versus those with missed ACG.

CONCLUSIONS

Almost 1 in 11 patients referred by ophthalmologists to a tertiary glaucoma centre with a diagnosis of OAG were in fact found to have angle closure. Given the different treatment approaches for ACG versus OAG, this study suggests a need to strengthen angle evaluations.

Cost-effectiveness of community versus hospital eye service follow-up for patients with quiescent treated age-related macular degeneration alongside the ECHoES randomised trial

OBJECTIVES

To assess the cost-effectiveness of optometrist-led follow-up monitoring reviews for patients with quiescent neovascular age-related macular degeneration (nAMD) in community settings (including high street opticians) compared with ophthalmologist-led reviews in hospitals.

DESIGN

A model-based cost-effectiveness analysis with a 4-week time horizon, based on a 'virtual' non-inferiority randomised trial designed to emulate a parallel group design.

SETTING

A virtual internet-based clinical assessment, conducted at community optometry practices, and hospital ophthalmology clinics.

PARTICIPANTS

Ophthalmologists with experience in the age-related macular degeneration service; fully qualified optometrists not participating in nAMD shared care schemes.

INTERVENTIONS

The participating optometrists and ophthalmologists classified lesions from vignettes and were asked to judge whether any retreatment was required. Vignettes comprised clinical information, colour fundus photographs and optical coherence tomography images. Participants' classifications were validated against experts' classifications (reference standard). Resource use and cost information were attributed to these retreatment decisions.

MAIN OUTCOME MEASURES

Correct classification of whether further treatment is needed, compared with a reference standard.

RESULTS

The mean cost per assessment, including the subsequent care pathway, was £411 for optometrists and £397 for ophthalmologists: a cost difference of £13 (95% CI -£18 to £45). Optometrists were non-inferior to ophthalmologists with respect to the overall percentage of lesions correctly assessed (difference -1.0%; 95% CI -4.5% to 2.5%).

CONCLUSIONS

In the base case analysis, the slightly larger number of incorrect retreatment decisions by optometrists led to marginally and non-significantly higher costs. Sensitivity analyses that reflected different practices across eye hospitals indicate that shared care pathways between optometrists and ophthalmologists can be identified which may reduce demands on scant hospital resources, although in light of the uncertainty around differences in outcome and cost it remains unclear whether the differences between the 2 care pathways are significant in economic terms.

TRIAL REGISTRATION NUMBER

ISRCTN07479761; Pre-results.

Automated imaging technologies for the diagnosis of glaucoma: a comparative diagnostic study for the evaluation of the diagnostic accuracy, performance as triage tests and cost-effectiveness (GATE study)

BACKGROUND

Many glaucoma referrals from the community to hospital eye services are unnecessary. Imaging technologies can potentially be useful to triage this population.

OBJECTIVES

To assess the diagnostic performance and cost-effectiveness of imaging technologies as triage tests for identifying people with glaucoma.

DESIGN

Within-patient comparative diagnostic accuracy study. Markov economic model comparing the cost-effectiveness of a triage test with usual care.

SETTING

Secondary care.

PARTICIPANTS

Adults referred from the community to hospital eye services for possible glaucoma.

INTERVENTIONS

Heidelberg Retinal Tomography (HRT), including two diagnostic algorithms, glaucoma probability score (HRT-GPS) and Moorfields regression analysis (HRT-MRA); scanning laser polarimetry [glaucoma diagnostics (GDx)]; and optical coherence tomography (OCT). The reference standard was clinical examination by a consultant ophthalmologist with glaucoma expertise including visual field testing and intraocular pressure (IOP) measurement.

MAIN OUTCOME MEASURES

(1) Diagnostic performance of imaging, using data from the eye with most severe disease. (2) Composite triage test performance (imaging test, IOP measurement and visual acuity measurement), using data from both eyes, in correctly identifying clinical management decisions, that is 'discharge' or 'do not discharge'. Outcome measures were sensitivity, specificity and incremental cost per quality-adjusted life-year (QALY).

RESULTS

Data from 943 of 955 participants were included in the analysis. The average age was 60.5 years (standard deviation 13.8 years) and 51.1% were females. Glaucoma was diagnosed by the clinician in at least one eye in 16.8% of participants; 37.9% of participants were discharged after the first visit. Regarding diagnosing glaucoma, HRT-MRA had the highest sensitivity [87.0%, 95% confidence interval (CI) 80.2% to 92.1%] but the lowest specificity (63.9%, 95% CI 60.2% to 67.4%) and GDx had the lowest sensitivity (35.1%, 95% CI 27.0% to 43.8%) but the highest specificity (97.2%, 95% CI 95.6% to 98.3%). HRT-GPS had sensitivity of 81.5% (95% CI 73.9% to 87.6%) and specificity of 67.7% (95% CI 64.2% to 71.2%) and OCT had sensitivity of 76.9% (95% CI 69.2% to 83.4%) and specificity of 78.5% (95% CI 75.4% to 81.4%). Regarding triage accuracy, triage using HRT-GPS had the highest sensitivity (86.0%, 95% CI 82.8% to 88.7%) but the lowest specificity (39.1%, 95% CI 34.0% to 44.5%), GDx had the lowest sensitivity (64.7%, 95% CI 60.7% to 68.7%) but the highest specificity (53.6%, 95% CI 48.2% to 58.9%). Introducing a composite triage station into the referral pathway to identify appropriate referrals was cost-effective. All triage strategies resulted in a cost reduction compared with standard care (consultant-led diagnosis) but with an associated reduction in effectiveness. GDx was the least costly and least effective strategy. OCT and HRT-GPS were not cost-effective. Compared with GDx, the cost per QALY gained for HRT-MRA is £22,904. The cost per QALY gained with current practice is £156,985 compared with HRT-MRA. Large savings could be made by implementing HRT-MRA but some benefit to patients will be forgone. The results were sensitive to the triage costs.

CONCLUSIONS

Automated imaging can be effective to aid glaucoma diagnosis among individuals referred from the community to hospital eye services. A model of care using a triage composite test appears to be cost-effective.

FUTURE WORK

There are uncertainties about glaucoma progression under routine care and the cost of providing health care. The acceptability of implementing a triage test needs to be explored.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The Prevalence of Visual Impairment in People with Dementia (the PrOVIDe study): a cross-sectional study of people aged 60–89 years with dementia and qualitative exploration of individual, carer and professional perspectives

Background

The prevalence of visual impairment (VI) and dementia increases with age and these conditions may coexist, but few UK data exist on VI among people with dementia.

Objectives

To measure the prevalence of eye conditions causing VI in people with dementia and to identify/describe reasons for underdetection or inappropriate management.

Design

Stage 1 – cross-sectional prevalence study. Stage 2 – qualitative research exploring participant, carer and professional perspectives of eye care.

Setting

Stage 1 – 20 NHS sites in six English regions. Stage 2 – six English regions.

Participants

Stage 1 – 708 participants with dementia (aged 60–89 years): 389 lived in the community (group 1) and 319 lived in care homes (group 2). Stage 2 – 119 participants.

Interventions

Stage 1 gathered eye examination data following domiciliary sight tests complying with General Ophthalmic Services requirements and professional guidelines. Cognitive impairment was assessed using the Standardised Mini-Mental State Examination (sMMSE) test, and functional ability and behaviour were assessed using the Bristol Activities of Daily Living Scale and Cambridge Behavioural Inventory – Revised. Stage 2 involved individual interviews (36 people with dementia and 11 care workers); and separate focus groups (34 optometrists; 38 family and professional carers).

Main outcome measures.

VI defined by visual acuity (VA) worse than 6/12 or worse than 6/18 measured before and after refraction.

Results

Stage 1 – when participants wore their current spectacles, VI prevalence was 32.5% [95% confidence interval (CI) 28.7% to 36.5%] and 16.3% (95% CI 13.5% to 19.6%) for commonly used criteria for VI of VA worse than 6/12 and 6/18, respectively. Of those with VI, 44% (VA < 6/12) and 47% (VA < 6/18) were correctable with new spectacles. Almost 50% of remaining uncorrectable VI (VA < 6/12) was associated with cataract, and was, therefore, potentially remediable, and one-third was associated with macular degeneration. Uncorrected/undercorrected VI prevalence (VA < 6/12) was significantly higher in participants in care homes (odds ratio 2.19, 95% CI 1.30 to 3.73;p < 0.01) when adjusted for age, sex and sMMSE score. VA could not be measured in 2.6% of group 1 and 34.2% of group 2 participants (p < 0.01). The main eye examination elements (excluding visual fields) could be performed in > 80% of participants. There was no evidence that the management of VI in people with dementia differed from that in older people in general. Exploratory analysis suggested significant deficits in some vision-related aspects of function and behaviour in participants with VI. Stage 2 key messages – carers and care workers underestimated how much can be achieved in an eye examination. People with dementia and carers were unaware of domiciliary sight test availability. Improved communication is needed between optometrists and carers; optometrists should be informed of the person’s dementia. Tailoring eye examinations to individual needs includes allowing extra time. Optometrists wanted training and guidance about dementia. Correcting VI may improve the quality of life of people with dementia but should be weighed against the risks and burdens of undergoing examinations and cataract surgery on an individual basis.

Limitations

Sampling bias is possible owing to quota-sampling and response bias.

Conclusions

The prevalence of VI is disproportionately higher in people with dementia living in care homes. Almost 50% of presenting VI is correctable with spectacles, and more with cataract surgery. Areas for future research are the development of an eye-care pathway for people with dementia; assessment of the benefits of early cataract surgery; and research into the feasibility of specialist optometrists for older people.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Factors influencing accuracy of referral and the likelihood of false positive referral by optometrists in Bradford, United Kingdom

AIMS

Levels of false positive referral to ophthalmology departments can be high. This study aimed to evaluate commonality between false positive referrals in order to find the factors which may influence referral accuracy.

METHODS

In 2007/08, a sample of 431 new Ophthalmology referrals from the catchment area of Bradford Royal Infirmary were retrospectively analysed.

RESULTS

The proportion of false positive referrals generated by optometrists decreases with experience at a rate of 6.2% per year since registration (p<0.0001). Community services which involved further investigation done by the optometrist before directly referring to the hospital were 2.7 times less likely to refer false positively than other referral formats (p=0.007). Male optometrists were about half as likely to generate a false positive referral than females (OR=0.51, p=0.008) and as multiple/corporate practices in the Bradford area employ less experienced and more female staff, independent practices generate about half the number of false positive referrals (OR=0.52, p=0.005).

CONCLUSIONS

Clinician experience has the greatest effect on referral accuracy although there is also a significant effect of gender with women tending to refer more false positives. This may be due to a different approach to patient care and possibly a greater sensitivity to litigation. The improved accuracy of community services (which often refer directly after further investigation) supports further growth of these schemes.

A comparative study of glaucoma referrals in Southeast Scotland: effect of the new general ophthalmic service contract, Eyecare integration pilot programme and NICE guidelines

Background

Glaucoma is a progressive disease responsible for the second commonest cause of blindness in the UK. Identifying appropriate patients for hospital care remains an ongoing challenge for all UK hospital glaucoma services. The purpose of our study is to evaluate accuracy and outcome of community optometry referrals before and after implementation of the new general ophthalmic service contract in 2006, the Eyecare Integration Programme pilot in 2008 and the effect of NICE guidelines in glaucoma in 2009, over a 12-year period

Methods

A retrospective case analysis using a glaucoma electronic patient record was performed encompassing two six-year periods, 2000–2006 (Group A), and 2007–2012 (Group B).

Results

One thousand six hundred twenty-two new patients’ records were analysed. Waiting times reduced from 12.3 to 9.4 weeks. Significantly more patients kept first appointment (p = 0.0002) in group B. Glaucoma symptoms were significantly more in group A (p <0.0001) and only three patients lost Snellen’ visual acuity before appointment in group B compared to 12 in group A. Documentation of intraocular pressure was made in 74.1 % of Group A and 75.9 % of Group B, optic disc appearance in 85.4 % of Group A, and 93 % of Group B and visual fields in 84.4 % of Group A and 81.3 % of Group B. Significantly less normal (p < 0,0001), more glaucoma suspects (p < 0.0001), more open angle glaucoma (p = 0.0006) and fewer other conditions (p = 0.0024) were present in group B, compared to group A.

Conclusion

Patients were referred earlier with shorter waiting times for hospital appointments with the new Scottish general ophthalmic service and Eyecare Integration Programme. Additionally there were fewer false positive referrals with more diagnosis of glaucomatous disease. We discuss the benefits of these national screening and referral pathways together with their limitations and further refinements.

Diagnostic Accuracy of Nonmydriatic Fundus Photography for the Detection of Glaucoma in Diabetic Patients

Purpose. To determine the diagnostic accuracy for glaucoma of a set of criteria with nonmydriatic monoscopic fundus photography (NMFP) in diabetics. Methods. Diabetics recruited from a screening program for diabetic retinopathy and diabetic glaucoma patients recruited from our glaucoma unit were included. Any patient with evidence of diabetic retinopathy was excluded. Diabetic patients had to have no visual field defects to be included as controls. Glaucoma patients had to have a glaucomatous field defect in at least one eye to be included. One NMFP was taken per eye for all subjects. These photographs were evaluated by two masked glaucoma specialists for the presence of the following: bilateral cup to disc (C/D) ratio ≥0.6, notching or thinning of the neuroretinal rim, disc hemorrhages, and asymmetry in the C/D ratio between both eyes ≥0.2. This evaluation led to a dichotomous classification: if any of the above criteria was present, the patient was classified as glaucoma. If none were present, the patient was classified as normal. Results. 72 control subjects and 72 glaucoma patients were included. Evaluation of NMFP had a sensitivity of 79.17% and a specificity of 80.56% for specialist 1 and a sensitivity of 72.22% and a specificity of 88.88% for specialist 2 for the detection of glaucoma. The overall accuracy was 79.83% and 80.55%, respectively. Discussion. NMFP evaluation by a glaucoma specialist may be useful for the detection of glaucoma in diabetics.

A survey of current and anticipated use of standard and specialist equipment by UK optometrists

PURPOSE

To investigate current and anticipated use of equipment and information technology (IT) in community optometric practice in the UK, and to elicit optometrists' views on adoption of specialist equipment and IT.

METHODS

An anonymous online questionnaire was developed, covering use of standard and specialist diagnostic equipment, and IT. The survey was distributed to a random sample of 1300 UK College of Optometrists members.

RESULTS

Four hundred and thirty-two responses were received (response rate = 35%). Enhanced (locally commissioned) or additional/separately contracted services were provided by 73% of respondents. Services included glaucoma repeat measures (30% of respondents), glaucoma referral refinement (22%), fast-track referral for wet age-related macular degeneration (48%), and direct cataract referral (40%). Most respondents (88%) reported using non-contact/pneumo tonometry for intra-ocular pressure measurement, with 81% using Goldmann or Perkins tonometry. The most widely used item of specialist equipment was the fundus camera (74% of respondents). Optical Coherence Tomography (OCT) was used by 15% of respondents, up from 2% in 2007. Notably, 43% of those anticipating purchasing specialist equipment in the next 12 months planned to buy an OCT. 'Paperless' records were used by 39% of respondents, and almost 80% of practices used an electronic patient record/practice management system. Variations in responses between parts of the UK reflect differences in the provision of the General Ophthalmic Services contract or community enhanced services. There was general agreement that specialised equipment enhances clinical care, permits increased involvement in enhanced services, promotes the practice and can be used as a defence in clinico-legal cases, but initial costs and ongoing maintenance can be a financial burden. Respondents generally agreed that IT facilitates administrative flow and secure exchange of health information, and promotes a state-of-the-art practice image. However, use of IT may not save examination time; its dynamic nature necessitates frequent updates and technical support; the need for adequate training is an issue; and security of data is also a concern.

CONCLUSION

UK optometrists increasingly employ modern equipment and IT services to enhance patient care and for practice management. While the clinical benefits of specialist equipment and IT are appreciated, questions remain as to whether the investment is cost-effective, and how specialist equipment and IT may be used to best advantage in community optometric practice.

Cambridge community Optometry Glaucoma Scheme

BACKGROUND

With a higher life expectancy, there is an increased demand for hospital glaucoma services in the United Kingdom.

DESIGN

The Cambridge community Optometry Glaucoma Scheme (COGS) was initiated in 2010, where new referrals for suspected glaucoma are evaluated by community optometrists with a special interest in glaucoma, with virtual electronic review and validation by a consultant ophthalmologist with special interest in glaucoma.

PARTICIPANTS

1733 patients were evaluated by this scheme between 2010 and 2013.

METHODS

Clinical assessment is performed by the optometrist at a remote site. Goldmann applanation tonometry, pachymetry, monoscopic colour optic disc photographs and automated Humphrey visual field testing are performed. A clinical decision is made as to whether a patient has glaucoma or is a suspect, and referred on or discharged as a false positive referral. The clinical findings, optic disc photographs and visual field test results are transmitted electronically for virtual review by a consultant ophthalmologist.

MAIN OUTCOME MEASURES

The number of false positive referrals from initial referral into the scheme.

RESULTS

Of the patients, 46.6% were discharged at assessment and a further 5.7% were discharged following virtual review. Of the patients initially discharged, 2.8% were recalled following virtual review. Following assessment at the hospital, a further 10.5% were discharged after a single visit.

CONCLUSIONS

The COGS community-based glaucoma screening programme is a safe and effective way of evaluating glaucoma referrals in the community and reducing false-positive referrals for glaucoma into the hospital system.

Glaucoma detection using optic disc images from the English national screening programme for diabetic retinopathy

PURPOSE

We performed this study to determine the positive predictive value of a Diabetic Retinopathy Screening Program (DRSP) in detecting early glaucoma using diabetic retinopathy screening images.

PATIENTS AND METHODS

The study was carried out on patients referred to the glaucoma clinic from the local DRSP. Retinal images considered by DRSP graders to show possible glaucomatous optic discs were referred to the final referral grader, a medical retina specialist (MR). The same images were independently graded by a glaucoma specialist (GS). GS-positive patients were referred to the glaucoma clinic. Possible outcomes at 1 year were true cases (patients found to have glaucoma or glaucoma suspects) or false cases (patients for whom a diagnosis of glaucoma was excluded).

RESULTS

Of 11,565 diabetic patients screened, 216 were suspected to have glaucoma after DRSP grading (1.87%). A total of 170 were graded glaucoma positive and referred to a clinic. At 1 year, 113 were true cases (98 per 10,000 screened with previously undiagnosed glaucoma or glaucoma suspect) and 22 were false cases and discharged from clinic (19 false positives per 10,000 screened). Of the 113 true cases, 89 were given a positive grade by the MR and 24 were given a negative grade, giving the DRSP a positive predictive value of 78.8% in detecting glaucoma in the population. Comparison of the MR and GS grading showed an agreement of 76.4%. The κ-coefficient was 0.404 (95% confidence interval, 0.272-0.536).

CONCLUSIONS

We conclude that optic discs imaging in DRSP can be useful as part of a glaucoma screening strategy to identify new disease within a diabetic population.

Glaucoma in southwest Nigeria: clinical presentation, family history and perceptions

Knowledge of the presentation pattern of glaucoma helps in providing more understanding of the disease, leading to better control. The aim of this study was to determine the presentation pattern among newly diagnosed glaucoma patients in Lagos, Nigeria. This was a multicenter cross-sectional survey of newly diagnosed glaucoma patients, recruited over a four-week period. Socio-demographic characteristics, presenting history, awareness and perception on glaucoma, and basic examination findings were obtained. A total of 208 patients, including 90 (43.2 %) females with a mean age of 53.9 years were recruited. One hundred and forty-three (68.7 %) were self-referred patients with a mean duration of symptoms of 2.6 years. Fifty-five (26.4 %) patients gave a history of glaucoma in at least one family member. Ninety-five patients (45.7 %) were aware that glaucoma can cause visual loss, but 69 (72.6 %) out of these believed the visual loss is reversible. Seventy (33.7 %) patients had been previously diagnosed with glaucoma elsewhere. From the 208 patients, 35.5 % had visual impairment (presenting visual acuity [VA] of <6/18 in the better eye), while 15.5 % were blind (presenting VA in better eye <3/60). Lack of glaucoma awareness, positive family history and illiteracy were associated with late presentation of glaucoma. Late presentation is still a major concern among glaucoma patients in Southwest Nigeria, and there is a need to intensify present efforts aimed at increasing public awareness, emphasising the irreversible nature of the disease, as well as encouraging at-risk groups such as first-degree relatives to go for screening.