Effectiveness of Elevated Intraocular Pressure as a Criterion for Glaucoma Referral After 6 Years of Follow-Up

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 knowledge, attitude, and practice of glaucoma among different cadres of optometrists

Purpose:

To assess the level of knowledge, attitude, and clinical practice of glaucoma among optometry students and optometry practitioners with different years of clinical experience and academic background.

Methods:

A survey with 20 questions on knowledge, attitude, and practice (KAP) of glaucoma was prepared and self-administered to optometry students and optometry practitioners practicing in an eye hospital/clinic/optical with varied years of clinical experience and education qualification.

Results:

Among the 558 participants, 57% were optometry practitioners and 43% were students. The knowledge scores among optometry practitioners increased significantly with an increase in the years of clinical experience (P < 0.001). Participants with master’s degrees scored higher than participants with bachelor’s degrees (P = 0.12). There was no statistically significant difference in knowledge scores based on the type of clinical practice - hospital, private practice, or optical (P = 0.39). Practicing optometrists who performed slit-lamp examination, gonioscopy, IOP measurements, and disc evaluation for the detection of glaucoma had significantly higher knowledge scores than those who did not perform these tests in their practice (P < 0.05). A positive attitude toward glaucoma learning through workshops and hands-on training was reported by optometrists and students.

Conclusion:

Knowledge about glaucoma was good among optometrists and optometry students and was better among those who handled the diagnostics. All the optometrists had a positive attitude toward enhancing their practice through proper training.

Intravitreal Corticosteroid Implantation in Diabetic Macular Edema: Updated European Consensus Guidance on Monitoring and Managing Intraocular Pressure

Intravitreal therapy for diabetic macular edema can, in susceptible patients, increase intraocular pressure (IOP). As uncontrolled IOP can potentially be sight threatening, monitoring is an essential component of patient management. It can be challenging for retina specialists to ensure that monitoring is rigorous enough to detect and resolve any potential problems at the earliest opportunity without it also being overburdensome for patients who have the lowest risk of developing an IOP rise. We have developed dynamic algorithms that: (1) tailor the frequency and extent of monitoring according to individual susceptibility and current IOP and (2) assist retina specialists in deciding when they should consider a referral to a glaucoma specialist. One algorithm is for patients with a relatively low susceptibility to developing an IOP rise (those whose baseline IOP is < 22 mmHg and who do not have a history of IOP events). Depending on their first post-implantation IOP check, the algorithm classifies them as: low risk if IOP remains < 22 mmHg; medium risk if IOP is 22-25 mmHg and any rise from baseline is < 10 mmHg; or high risk if IOP is > 25 mmHg or any rise from baseline is ≥ 10 mmHg. Thereafter, the algorithm guides on the frequency and extent of monitoring required in each of these groups and, if IOP rises or falls during treatment, patients may move up or down the risk groups accordingly. A different algorithm is provided for patients who are more susceptible to developing an IOP rise (those with a baseline IOP of ≥ 22 mmHg or a prior history of an IOP event). These patients need monitoring more closely so this algorithm has only medium- or high-risk classifications. These algorithms update the previous monitoring guidance by Goñi et al. (Goñi et al. in Ophthalmol Ther 5:47-61, 2016).