A survey of investigations used for the management of glaucoma in hospital service in the United Kingdom

Changes in glaucoma management following visual field testing and optical coherence tomography

BACKGROUND

Optimal utilisation of investigations in glaucoma management remains unclear. We aimed to assess whether a temporal association exists between such testing and management changes.

METHODS

Retrospective observational study using nationwide healthcare insurance claims database. Glaucoma outpatient encounters from patients aged ≥40 years with/without Humphrey visual field (HVF) and/or optical coherence tomography (OCT) were identified. An encounter was considered associated with an intervention if surgery occurred within 90 days, or if medication change or laser trabeculoplasty (LT) occurred within 30 days.

RESULTS

12 669 324 outpatient encounters of 1 863 748 individuals from 2003 to 2020 were included. HVF and OCT was performed during 32.8% and 22.2% of encounters respectively. Of the 36 763 (0.3%) encounters preceding surgery, 28.1% included HVF, 11.9% had OCT and 8.5% both. 79 181 (0.6%) visits preceded LT, of which 28.2% had HVF, 13.2% OCT and 9.3% both. Of the 515 899 (4.5%) encounters preceding medication changes, 29.1% had HVF, 16.7% OCT and 12.2% both. Compared with encounters with no investigations, those with HVF and/or OCT were associated with a 49% increased odds of a management change (p<0.001). In multivariate analyses, compared with encounters without investigations, visits with HVF alone had higher odds of subsequent surgery and LT, while HVF and/or OCT were associated with higher odds of medication change (p<0.001 for all).

CONCLUSION

Glaucoma therapeutic changes occurred following approximately 5% of outpatient encounters. Surgery and LT were more likely to occur following a visit with a HVF rather than an OCT, while either investigation was associated with a higher odds of medication change.

Structure-function assessment in glaucoma based on perimetric sensitivity and en face optical coherence tomography images of retinal nerve fiber bundles

Many studies have assessed structure-function relations in glaucoma, but most without topographical comparison across the central 30°. We present a method for assessing structure-function relations with en face images of retinal nerve fiber layer (RNFL) bundles allowing topographical comparison across much of this retinal area. Forty-four patients with glaucoma (median age 61 years) were recruited and tested with Optical Coherence Tomography (OCT) and perimetry. Six rectangular volume scans were gathered, and then montaged to provide en face views of the RNFL bundles. We calculated the proportion of locations showing a perimetric defect that also showed an en face RNFL defect; and the proportion of locations falling on an RNFL defect that also showed a perimetric defect. A perimetric defect for a location was defined as a total deviation (TD) value equal to or deeper than -4 dB. We found that the median (IQR) number of locations with abnormal RNFL bundle reflectance that also had abnormal TD was 78% (60%) and for locations with abnormal TD that also had abnormal RNFL bundle reflectance was 75% (44%). We demonstrated a potential approach for structure-function assessment in glaucoma by presenting a topographic reflectance map, confirming results of previous studies and including larger retinal regions.

Review of glaucoma management in France

PURPOSE

To conduct a review of glaucoma management in France.

METHOD

A 15-question survey was sent to ophthalmologists listed in the journal Réalités Ophtalmologiques and the Syndicat National des Ophtalmologues de France.

RESULTS

459/471 responses were analyzed. Gonioscopy was performed by 64.7% of respondents with a Goldmann three-mirror lens, by 51.4% with a four-mirror lens, and 8.2% preferred to perform the procedure with anterior segment imaging. The visual field was reported to be interpreted without difficulty by 87.8% of the practitioners, and 54.0% utilize a progression software. Ultrasound biomicroscopy was reported to be interpreted without difficulty by 20.0% of practitioners. In cases of severe ocular hypertonia with flat bleb in early postoperative trabeculectomy, 61.7% chose ocular massage as a first-line treatment, 52.9% chose laser suture lysis, 50.5% utilized needling, and 24.8% employed hypotonizing eyedrops. In case of severe ocular hypertonia with flat bleb in early postoperative deep sclerectomy, 53.2% chose goniopuncture as their first treatment, 34.4% employed needling, 31.8% utilized ocular massage, and 23.3% chose hypotonizing eyedrops. The selective laser trabeculoplasty is used as soon as the diagnosis is made by 37.5%, in association with a mono or dual therapy by 93.2%, after trying different combinations of eyedrops by 45.5%, when the visual field deteriorates despite a normalized intraocular pressure by 46.6%, and in cases of hypertonia after filtering surgery by 19.2%. Concerning management for primary angle-closure glaucoma, 80.8% considered peripheral iridotomy, and 18.7% utilized cataract surgery.

CONCLUSION

The diversity of responses concerning glaucoma management should draw attention to the need for standardized practices.

Factors Influencing Career Decisions and Satisfaction Among Newly Practicing Ophthalmologists

PURPOSE

To describe the career choices of newly practicing ophthalmologists and explore factors influencing career decisions and satisfaction.

METHODS

A cross-sectional study was conducted using data from an electronic survey of ophthalmologists who completed training within the prior 5 years. The survey included questions about demographic information, medical education, current practice, factors affecting career choices, and career satisfaction. Statistical comparisons were made based on gender, type of practice, subspecialty training, and practice area.

RESULTS

Surveys were completed by 696 (32%) newly practicing ophthalmologists, including 276 (40%) women, 179 (29%) academicians, and 465 (67%) subspecialists. A higher proportion of female respondents entered academics than male respondents (36% vs 26%, P = .009). Female and male respondents pursued fellowship training with similar frequency (64% vs 68%, P = .32), but men were more likely to seek vitreoretinal fellowships (30% vs 11%, P < .001) and women were more likely to undertake fellowships in pediatric ophthalmology (21% vs 8%, P < .001), uveitis (10% vs 2%, P = .002), and neuro-ophthalmology (6% vs 2%, P = .042). A total of 514 (83%) respondents reported being happy with work life.

CONCLUSIONS

The career choices of newly practicing ophthalmologists differ based on gender, type of practice, subspecialty training, and practice area. Many factors affect career decisions, and they have varying influence on subgroups within ophthalmology. Ophthalmologists have high levels of career satisfaction. This information may prove useful when developing workforce strategies to meet future eye care needs. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

A Comparative Study between Swedish Interactive Thresholding Algorithm Faster and Swedish Interactive Thresholding Algorithm Standard in Glaucoma Patients

Purpose:

To compare the results of the new strategy Swedish Interactive Thresholding Algorithm (SITA) Faster to the results of SITA Standard in patients with glaucoma.

Methods:

This was a cross-sectional study of 49 patients with glaucoma and previous experience with standard automated perimetry. Two consecutive tests were performed in random order, one with SITA Standard and another one with SITA Faster, in the studied eye of each patient. Comparisons were made for test time, mean deviation (MD), visual field index (VFI), and number of depressed points in pattern deviation map and total deviation map for every level of significance.

Results:

The average test time was 56% shorter with SITA Faster (P < 0.001). The intraclass correlation coefficient (ICC) for MD and VFI showed excellent agreement between both strategies, ICC = 0.98 (95% confidence interval [CI]: 0.96, 0.99) and ICC = 0.97 (95% CI: 0.95, 0.99), respectively. For the number of depressed points in total deviation map and pattern deviation map, ICC demonstrated good agreement with values between 0.8 and 0.95.

Conclusions:

Our study shows that SITA Faster is a shorter test with strong agreement with SITA Standard parameters. These results suggest that SITA Faster could replace SITA Standard for glaucoma diagnosis.

Clinical Evaluation of Swedish Interactive Thresholding Algorithm-Faster Compared With Swedish Interactive Thresholding Algorithm-Standard in Normal Subjects, Glaucoma Suspects, and Patients With Glaucoma

PURPOSE

To compare the visual fields results obtained using the Swedish interactive thresholding algorithm-Standard (SS) and the Swedish interactive thresholding algorithm-Faster (SFR) in normal subjects, glaucoma suspects, and patients with glaucoma and to quantify potential time-saving benefits of the SFR algorithm.

DESIGN

Prospective, cross-sectional study.

METHODS

One randomly selected eye from 364 patients (77 normal subjects, 178 glaucoma suspects, and 109 patients with glaucoma) seen in a single institution underwent testing using both SS and SFR on the Humphrey Field Analyzer. Cumulative test time using each algorithm was compared after accounting for different rates of test reliability. Pointwise and cluster analysis was performed to determine whether there were systematic differences between algorithms.

RESULTS

Using SFR had a greater rate of unreliable results (29.3%) compared with SS (7.7%, P < .0001). This was mainly because of high false positive rates and seeding point errors. However, modeled test times showed that using SFR could obtain a greater number of reliable results within a shorter period of time. SFR resulted in higher sensitivity values (on average 0.5 dB for patients with glaucoma) that was greater under conditions of field loss (<19 dB). Cluster analysis showed no systematic patterns of sensitivity differences between algorithms.

CONCLUSIONS

After accounting for different rates of test reliability, SFR can result in significant time savings compared with SS. Clinicians should be cognizant of false positive rates and seeding point errors as common sources of error for SFR. Results between algorithms are not directly interchangeable, especially if there is a visual field deficit <19 dB.

A strategy for OCT estimation of the optic nerve head pigment epithelium central limit-inner limit of the retina minimal distance, PIMD-2π

PURPOSE

To develop a semi-automatic algorithm for estimation of pigment epithelium central limit-inner limit of the retina minimal distance averaged over 2π radians (PIMD-2π) and to estimate the precision of the algorithm. Further, the variances in estimates of PIMD-2π were to be estimated in a pilot sample of glaucomatous eyes.

METHODS

Three-dimensional cubes of the optic nerve head (ONH) were captured with a commercial SD-OCT device. Raw cube data were exported for semi-automatic segmentation. The inner limit of the retina was automatically detected. Custom software aided the delineation of the ONH pigment epithelium central limit resolved in 500 evenly distributed radii. Sources of variation in PIMD estimates were analysed with an analysis of variance.

RESULTS

The estimated variance for segmentations and angles was 130 μm² and 1280 μm² , respectively. Considering averaging eight segmentations, a 95 % confidence interval for mean PIMD-2π was estimated to 212 ± 10 μm (df = 7). The coefficient of variation for segmentation was estimated at 0.05. In the glaucomatous eyes, the within-subject variance for captured volumes and for segmentations within volumes was 10 μm² and 50 μm² , respectively.

CONCLUSION

The developed semi-automatic algorithm enables estimation of PIMD-2π in glaucomatous eyes with relevant precision using few segmentations of each captured volume.

Understanding practice patterns of glaucoma sub-specialists in India

AIM

To obtain information on the prevailing practice patterns of glaucoma specialists in India.

METHODS

Glaucoma specialists attending the Annual Conference of the Glaucoma Society of India (GSI) were surveyed. This survey, conducted in 2013, was based on an interactive audience response system.

RESULTS

The information was obtained from 146 glaucoma specialists. Approximately half (n=83; 57%) had ≥10y of experience in managing glaucoma and were in institutional practice (n=74, 51%). Goldmann applanation tonometry was preferred by 103 (72%) specialists whilst n=25 (17.4%) used non-contact tonometer. Indentation gonioscopy was favoured by two-thirds (n=90, 66%) whereas stereoscopic optic disc examination and visual fields using Humphrey perimeter was performed by a majority of the specialists surveyed (n=115, 86% and n=114; 83% respectively). Nearly three quarter specialists (n=96; 72%) preferred optical coherence tomography for imaging. The primary choice for treatment of angle closure disease and primary open angle glaucoma was laser (iridotomy, n=117; 93%) and medical management (prostaglandin analogue, n=104; 78%), respectively. Approximately only a third of the specialists surveyed (n=37; 28%) were performing both trabeculectomy and implantation of a glaucoma drainage device and about half (n=64; 47%) were not operating on congenital glaucoma at all.

CONCLUSION

This survey has found conformance with preferred practice patterns in several areas of diagnosis and management of glaucoma, but there was diversity in a few areas. The information is a significant step towards improvement of glaucoma care in India, including planning for future strategies.

Prevalent practice patterns in glaucoma: Poll of Indian ophthalmologists at a national conference

Purpose:

The aim of this study is to explore and compare the prevailing practice patterns in the diagnosis and management of glaucoma among subspecialists and general ophthalmologists in India.

Materials and Methods:

This is an interactive audience response system (ARS) based poll of ophthalmologists attending the annual conference of the Glaucoma Society of India in 2013.

Results:

The information was obtained from 379 ophthalmologists (146 glaucoma specialists, 54 nonglaucoma subspecialists, and 179 general ophthalmologists). The majority of polled ophthalmologists (236; 62%) had 10 or more years of experience in ophthalmology. The glaucoma specialists differed from nonglaucomatologists in their preference for Goldmann applanation tonometer (P < 0.01), four-mirror gonioscope (P < 0.01), Humphrey perimeter (P < 0.01), laser peripheral iridotomy in primary angle closure disease (P = 0.03), postiridotomy gonioscopy (P < 0.01), and usage of antifibrotic agents during filtering surgery (P < 0.01). Optical coherence tomography was the most preferred imaging modality and was utilized more often by the subspecialists than general ophthalmologists. The ophthalmologists also differed in their choice of antiglaucoma medications. More glaucoma specialists were performing surgery on children with congenital glaucoma (P < 0.01), implanting glaucoma drainage devices (P < 0.01), and using scientific journals to upgrade knowledge (P = 0.03) than the other ophthalmologists.

Conclusions:

This poll is the first of its kind in India, in its usage of the ARS, and in comparing the practice patterns of care for glaucoma among subspecialists and general ophthalmologists. It has revealed substantial diversity in a few areas among those who did and did not receive specialty training in glaucoma.

Variance components in confocal scanning laser tomography measurements of neuro-retinal rim area and the effect of repeated measurements on the power to detect loss over time

PURPOSE

To estimate the variation in measurements of neuro-retinal rim area (NRA) determined by confocal scanning laser tomography and consequences for clinical follow-up.

METHODS

Altogether, 24 healthy subjects were randomized on -320 μm, Moorfields and Standard NRA plane strategies. Additionally, NRA was measured in 32 glaucoma subjects. Variance components for subjects, visits and measurements were estimated with analysis of variance. Sample sizes required to detect a 6.0 × 10^-2  mm² NRA change were estimated assuming a significance level of 0.05 and a power of 0.8. Consequences for independent group, and paired comparison design, respectively, were analysed. Further, precision in estimates within subjects over time was investigated.

RESULTS

The variation of NRA among subjects was considerably larger than the variation among visits and measurements. For glaucoma subjects, the variation among visits and measurements were of the same order but larger than in healthy subjects. It was found that independent group comparisons require inconveniently large sample sizes. Within-subject paired comparisons over time require sample sizes of below 15 subjects. The estimated variations for glaucoma subjects imply that 54 months of follow-up is required for detection of change from baseline.

CONCLUSIONS

The variance for subjects is substantial in relation to those for visits and measurements. Cross-sectional independent group comparisons of levels of NRA are unsuitable, due to considerable subject variation. Levels of NRA differences within subjects between visits can be estimated with acceptable precision. Neuro-retinal rim area (NRA) measurement can be used for long-term follow-up of glaucoma progression.

Optic nerve head and fibre layer imaging for diagnosing glaucoma

BACKGROUND

The diagnosis of glaucoma is traditionally based on the finding of optic nerve head (ONH) damage assessed subjectively by ophthalmoscopy or photography or by corresponding damage to the visual field assessed by automated perimetry, or both. Diagnostic assessments are usually required when ophthalmologists or primary eye care professionals find elevated intraocular pressure (IOP) or a suspect appearance of the ONH. Imaging tests such as confocal scanning laser ophthalmoscopy (HRT), optical coherence tomography (OCT) and scanning laser polarimetry (SLP, as used by the GDx instrument), provide an objective measure of the structural changes of retinal nerve fibre layer (RNFL) thickness and ONH parameters occurring in glaucoma.

OBJECTIVES

To determine the diagnostic accuracy of HRT, OCT and GDx for diagnosing manifest glaucoma by detecting ONH and RNFL damage.

SEARCH METHODS

We searched several databases for this review. The most recent searches were on 19 February 2015.

SELECTION CRITERIA

We included prospective and retrospective cohort studies and case-control studies that evaluated the accuracy of OCT, HRT or the GDx for diagnosing glaucoma. We excluded population-based screening studies, since we planned to consider studies on self-referred people or participants in whom a risk factor for glaucoma had already been identified in primary care, such as elevated IOP or a family history of glaucoma. We only considered recent commercial versions of the tests: spectral domain OCT, HRT III and GDx VCC or ECC.

DATA COLLECTION AND ANALYSIS

We adopted standard Cochrane methods. We fitted a hierarchical summary ROC (HSROC) model using the METADAS macro in SAS software. After studies were selected, we decided to use 2 x 2 data at 0.95 specificity or closer in meta-analyses, since this was the most commonly-reported level.

MAIN RESULTS

We included 106 studies in this review, which analysed 16,260 eyes (8353 cases, 7907 controls) in total. Forty studies (5574 participants) assessed GDx, 18 studies (3550 participants) HRT, and 63 (9390 participants) OCT, with 12 of these studies comparing two or three tests. Regarding study quality, a case-control design in 103 studies raised concerns as it can overestimate accuracy and reduce the applicability of the results to daily practice. Twenty-four studies were sponsored by the manufacturer, and in 15 the potential conflict of interest was unclear.Comparisons made within each test were more reliable than those between tests, as they were mostly based on direct comparisons within each study.The Nerve Fibre Indicator yielded the highest accuracy (estimate, 95% confidence interval (CI)) among GDx parameters (sensitivity: 0.67, 0.55 to 0.77; specificity: 0.94, 0.92 to 0.95). For HRT measures, the Vertical Cup/Disc (C/D) ratio (sensitivity: 0.72, 0.60 to 0.68; specificity: 0.94, 0.92 to 0.95) was no different from other parameters. With OCT, the accuracy of average RNFL retinal thickness was similar to the inferior sector (0.72, 0.65 to 0.77; specificity: 0.93, 0.92 to 0.95) and, in different studies, to the vertical C/D ratio.Comparing the parameters with the highest diagnostic odds ratio (DOR) for each device in a single HSROC model, the performance of GDx, HRT and OCT was remarkably similar. At a sensitivity of 0.70 and a high specificity close to 0.95 as in most of these studies, in 1000 people referred by primary eye care, of whom 200 have manifest glaucoma, such as in those who have already undergone some functional or anatomic testing by optometrists, the best measures of GDx, HRT and OCT would miss about 60 cases out of the 200 patients with glaucoma, and would incorrectly refer 50 out of 800 patients without glaucoma. If prevalence were 5%, e.g. such as in people referred only because of family history of glaucoma, the corresponding figures would be 15 patients missed out of 50 with manifest glaucoma, avoiding referral of about 890 out of 950 non-glaucomatous people.Heterogeneity investigations found that sensitivity estimate was higher for studies with more severe glaucoma, expressed as worse average mean deviation (MD): 0.79 (0.74 to 0.83) for MD < -6 db versus 0.64 (0.60 to 0.69) for MD ≥ -6 db, at a similar summary specificity (0.93, 95% CI 0.92 to 0.94 and, respectively, 0.94; 95% CI 0.93 to 0.95; P < 0.0001 for the difference in relative DOR).

AUTHORS' CONCLUSIONS

The accuracy of imaging tests for detecting manifest glaucoma was variable across studies, but overall similar for different devices. Accuracy may have been overestimated due to the case-control design, which is a serious limitation of the current evidence base.We recommend that further diagnostic accuracy studies are carried out on patients selected consecutively at a defined step of the clinical pathway, providing a description of risk factors leading to referral and bearing in mind the consequences of false positives and false negatives in the setting in which the diagnostic question is made. Future research should report accuracy for each threshold of these continuous measures, or publish raw data.

The Capacity of Eye Care Services for Patients with Glaucoma in Botswana

PURPOSE

To evaluate current delivery of glaucoma care in Botswana; in particular, the service infrastructure available and glaucoma-related workload.

METHODS

A multi-center cross-sectional study was undertaken comprising government eye care institutions and ophthalmic personnel across Botswana. Data on human resources, equipment types and numbers, diagnostic criteria routinely used, treatments routinely provided, and new and repeat glaucoma consultations were obtained through quantitative and qualitative surveys.

RESULTS

In 27 government eye care institutions there were two general ophthalmologists, neither of whom had a subspecialty interest in glaucoma, 64 ophthalmic nurses, two optometrists, one low vision therapist, one refractionist, and two equipment technicians. Only 8.5% of available ophthalmic human resources were taken up with provision of glaucoma care. About 1/3 of hospitals did not have tonometers, most primary hospitals lacked slit lamp biomicroscopes and most hospitals lacked sensitive diagnostic equipment. A diagnosis of glaucoma was made by either an ophthalmic nurse or an ophthalmologist, but only 10% of institutions could meet recommendations for follow-up assessment. Topical glaucoma medications were prescribed by almost all hospital clinics, usually by ophthalmic nurses. Drug choices were largely determined by local availability. Glaucoma surgery accounted for 0.8% of total eye operations. Glaucoma patients took up 8.5% of total clinic visits. The total number of glaucoma visits was highest in the two hospitals with ophthalmologists. New glaucoma cases took up 10.3% of total glaucoma visits.

CONCLUSION

This study highlights the challenges faced in caring for glaucoma patients in Botswana; in particular, lack of professional human resources, equipment and availability of effective treatments.

Clinic-based glaucoma care in the era of surgical subspecialization

PURPOSE

To evaluate the impact of surgeon practice profile on clinic-based glaucoma care.

DESIGN

Population-based study of glaucoma care patterns in Ontario, Canada from 2000-2010.

METHODS

Using comprehensive physician services data from the Ontario Health Insurance Plan database, ophthalmologists were divided into 5 surgical practice subgroups. The role of each subgroup in the provision of glaucoma care was evaluated. Consultations and office visits were used to assess nonsurgical care, while laser trabeculoplasty procedures were used to assess clinic-based procedural care.

RESULTS

Between 2000 and 2010, the population rate of glaucoma consultations and follow-up visits provided by ophthalmologists who do not perform incisional glaucoma surgery increased at average annual rates of 1.6% (P < .0002) and 3.3% (P < .0001), respectively. In contrast, no significant growth in the rate of glaucoma consultations or follow-up visits provided by glaucoma surgeons was observed (0.8%/year [P = .2] for consultations; 0.2%/year [P = .6] for follow-up visits). Between 2000 and 2010, the rate of laser trabeculoplasty procedures provided by ophthalmologists who do not perform incisional glaucoma surgery increased 19.3% annually (P < .0001), while growth among glaucoma surgeons was more modest (annual growth of 9.2% [P = .0002]).

CONCLUSIONS

While subspecialization is a growing reality in most areas of medicine, we found that the provision of clinic-based glaucoma care remains dependent on ophthalmologists who do not perform incisional glaucoma surgery. With increasing focus on integrated care, these findings will have important implications for residency education programs and their accrediting bodies and will inform decisions of health care policymakers, hospitals, and academic departments.

A survey of attitudes of glaucoma subspecialists in England and Wales to visual field test intervals in relation to NICE guidelines

OBJECTIVES

To establish the attitudes of glaucoma specialists to the frequency of visual field (VF) testing in the UK, using the NICE recommendations as a standard for ideal practice.

DESIGN

Interview and postal survey.

SETTING

UK and Eire Glaucoma Society national meeting 2011 in Manchester, UK, with a second round of surveys administered by post.

PARTICIPANTS

All consultant glaucoma specialists in England and Wales were invited to complete the survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

(1) Compliance of assigned follow-up VF intervals with NICE guidelines for three hypothetical patient scenarios, with satisfactory treated intraocular pressure and (a) no evidence of VF progression; (b) evidence of VF progression and (c) uncertainty about VF progression, and respondents were asked to provide typical follow-up intervals representative of their practice; (2) attitudes to research recommendations for six VF in the first 2 years for newly diagnosed patients with glaucoma.

RESULTS

70 glaucoma specialists completed the survey. For each of the clinical scenarios a, b and c, 14 (20%), 33 (47%) and 28 (40%) responses, respectively, fell outside the follow-up interval recommended by NICE. Nearly half of the specialists (46%) agreed that 6 VF tests in the first 2 years was ideal practice, while 16 (28%) said this was practice 'not possible', with many giving resources within the NHS setting as a limiting factor.

CONCLUSIONS

The results from this survey suggest that there is a large variation in attitudes to follow-up intervals for patients with glaucoma in the UK, with assigned intervals for VF testing which are, in many cases, inconsistent with the guidelines from NICE.

Glaucoma management in Sweden -- results from a nationwide survey

Purpose:

To report the results from a nationwide survey on glaucoma management in Sweden, performed as a part of an Open Angle Glaucoma project conducted by the Swedish Council on Health Technology Assessment 2004–2008.

Methods:

In 2005, a survey was distributed to all providers of glaucoma care in Sweden: public eye departments, public outpatient departments and private practices. The questionnaire included questions on number of examined patients, types of examinations during one defined week, internal organization and access to diagnostic equipment. The questionnaire was endorsed by the Swedish Ophthalmological Society. Reminders were sent out to nonresponders.

Results:

Response rate was high; 97% (33/34) of eye departments, 85% (39/46) of outpatient departments and 55% (69/125) of private practices. Out of 29 282 visits in ophthalmic care during the study week, 7737 (26%) were related to glaucoma. Diagnostic equipment was generally available; all public eye facilities and 92% of private practices had at least one computerized perimeter, while equipment for fundus photography/imaging was available at 100% of eye departments, 82% of outpatient departments and 62% of private practices. The number of visual field tests and fundus images was rather low. Survey results indicate that patients on the average underwent bilateral field testing every 2nd year and fundus imaging every 8th year.

Conclusion:

Glaucoma care generated about a quarter of all patient visits in Swedish ophthalmic care. Access to diagnostic facilities was good. To meet modern standards of glaucoma care, glaucoma damage must be measured and followed more closely than at the time of the survey.

The Peterborough scheme for community specialist optometrists in glaucoma: a feasibility study

PURPOSE

This study assessed the role of specialist optometrists who were working in the community and sharing the care for glaucoma patients with, and under close supervision of, a consultant ophthalmologist working in the Hospital Eye Services (HES) to ensure high-quality standards, safety, and care.

METHODS

From February 2005 onwards, the majority of all new glaucoma referrals to our eye department were diverted to our specialist optometrists in glaucoma (SOGs) in their own community practices. Selected patients in the HES setting who were already diagnosed with stable glaucoma were also transferred to the SOGs. The completed clinical finding details of the SOGs, including fundus photographs and Humphrey visual field tests, were scrutinised by the project lead.

RESULTS

This study included 1184 new patients seen by specialist optometrists between February 2005 and March 2007. A total of 32% of patients were referred on to the hospital, leaving the remaining 68% patients to be seen for at least their next consultation in the community by the SOGs. The following levels of disagreement were observed between SOGs and the project lead: on cup:disc ratio (11%), visual field interpretation (7%), diagnosis (12%), treatment plan (10%), and outcome (follow-up interval and location) (17%).

CONCLUSION

This study indicates that there is potential for a significant increase in the role of primary care optometry in glaucoma management. The study also confirms a need for a significant element of supervision and advice from a glaucoma specialist. The important issue of cost effectiveness is yet to be confirmed.