Glaucoma Care by Optoms in Bristol

This was another really good lecture! There was a HUGE amount of info in it that I can't hope to replicate here. Go back to the actual notes and read read read.

It's probably good to summarise glaucoma again. Hammer it in like. It's a variety of diseases with a common denominator - ACQUIRED PROGRESSIVE OPTIC NEUROPATHY. If it's untreated/unsufficiently treated it will lead to progressive loss of visual function. There are a variety of different causes and so a variety of different types/diagnoses. Let's categorise::::

• Open-Angle without ocular or systemic disorders - POAG, Normal Tension Glaucoma
• Angle closure without known ocular/systemic disorders - pupillary block glaucoma, combined mechanism glaucoma
• Developmental glaucomas - congenital, glaucomas assoc w/oc/systemic anomalies, 2ary glaucomas in childhood
• Glaucomas assoc w/oc/sys disorders - assoc w/disorders of endothelium, iris & cil body (pigmentary), lens, retina/choroid/vitreous, assoc w/intraocular tumours, elevated episcleral venous pressure, inflammation, steroid induced glaucoma, ocular trauma, haemorrhage, following intraoc surgery

Chronic Open Angle Glaucoma - Glau w/out ocular/systemic associations

• Epidemiology - onset from 35yr onwards, prevalence 2% (relatively common)
• Risk Factors - major ones are IOP and age, moderates are race and family history, minor are vasculopathy, vasospasm and lot central corneal thickness
• Subdivs - high pressure type (POAG), normal pressure type (Normal Tension Glau)
• Definition - multifactorial glaucoma w/characteristic progressive atrophy of ON head (not exactly sure of cause)
• Cause(s) - mechanical, vascular, autoimmune?
• Heredity - mostly unknown, few genes identified
• IOP Elevation - variety of angle degenerative changes
• Symptoms - none til advanced
• Signs - Physiological open angle, acquired disc/RNFL signs, VF signs
• Course - usually slowly progressive
• Visual prognosis is good cf age, how bad it is when first detected

Why should optoms take a greater involvement in glaucoma care?

• Causes blindness & visual morbidity
• Has substantial impact on the current NHS HES resources
• Optoms are already part of the pathway doing 95% of the glaucoma related referrals
• They have many of the tools/skills to equip them for an extended role
• The new prescribing legislation for optoms can be applied to glaucoma management
• College Glaucoma Higher Qualifications have been established
• NICE Glaucoma guidance is on the way
• The DoH trials of alternative glaucoma pathways have recently been completed
• International critical mass of glaucoma specialist optometrists

In 2004 'supplementary prescribers' were defined and in 2009 'independent prescribers'. Sup. prescribing extends the role of the prescriber to make better use of their knowledge and skills and is suitable for optometric co-management.

The Upcoming Clinical Challenge

Glaucoma is currently the second most common cause of CVI certifications. It has a better prognosis if treated in the disease's earlier stages. Early glaucoma is hard to identify. It's a chronic condition that requires lifelong review and is dominated by medical treatment. Obviously there is a public health issue as a significant proportion of cases may remain undetected.

The population of the UK is growing and ageing. There is expected to be a 12% growth in numbers and 8% shift towards the higher glaucoma prevalence age bracket (over 65 years). Life expectancy is also increasing (2002 women age 84, 2020 88) which obviously means more people having their glaucoma review. In summary, more people will be requiring more appointments for a longer period. Maths suggests that there'll be an extra 390,000 appts required per year by 2031 and current increases in ophthalmologist training are unlikely to meet this demand.

The Bristol Shared Care Scheme

Included peoples were glaucoma suspects, ocular hypertensives, stable/early/moderate POAG, PXF, Pigmentary Glau, px who can perform vf examinations, VA of 6/18 or better both eyes. People who are excluded - unstable glau, normal tension, 2ary glaus, narrow angle glau, any other existing ocular pathology, advanced VF loss and best corrected VA of 6/18 or less.

There was a study from 1993-1997 which showed that the optom and HES measurements were equally reliable and outcomes were comparable after two years of review. Px were more satisfied with having the check done at the local optom presumably because it was closer/easier to get to. The full cost of the assessments was cheaper if everyone was done at the hospital though. So after this study the scheme wasn't introduced. There was increased involvement of in house optoms within the Bristol eye hospital though