Shared Care: Optometric Management of Glaucoma

The glaucoma prevalence for europeans - one percent of ages 40-60, 2% of over 60s and >3% of those over 80. The risk factors are as follows

• Age, gender (F), race (african/afro-carribean)
• IOP, ON Head, Myopia/Hypermetropia
• Diabetes, systemic hypertension
• Family History (FH)
• Smoking, alcohol, socio-economic factors

If IOP is less than 15 glau is very unlikely. Anything between 15 and 25 is low tension. 25 upwards the risk of POAG goes up from 10% to about 35%

People with high diurnal variation are more likely to have glaucoma also. A glaucoma patient also has poor VA in mid range contrast sensitivity. You wouldn't normally spot this as most optoms just use a normal snellen w/high contrast. You could spot it w/a pelli robson though. Blue/Yellow fields are more sensitive when spotting the early visual loss.

There is ganglion cell damage in glaucoma. There are two theories behind this

1. Magno vulnerability where selective loss of magno cells (concerned w/good flicker/motion perception and more sensitive to low contrast stuff
2. Redundancy whereby magno and parvo cells are lost at the same rate but the larger number of parvo cells means the effect is less pronounced at high contrast

Glaucoma Management Pathway

1. Patient attends optom, has sight test. IOP = >21 w/applanation tonometry and/or vfd and/or suspicious discs. This results in the patient/optom making an appointment with an optom with a specialist interest in glaucoma or an OMP
2. Px attends that person and a full assessment is carried out according to protocol. A decision is taken whether the patient has ocular hypertension (OSI/OMP reviews) or can be discharged (return to optom) OR has glaucoma (treat or refer to HES). The px is advised and given further info
3. OSI/OMP relays data to HES and the HES reviews the data, advises regarding management and sets up review at HES if needed
4. OSI/OMP manages px in community setting w/regular reviews set in place. OSI/OMP relay data to the hospital if there's significant progression for HES review if req

Each different shared care scheme has its own recruitment, testing and re-referral criteria. Varies. eg Bristol - people who are included have stable POAG, pigmentary or pseudoexfoliative glaucoma but other glaucomas (ie stuff that needs surgery) is going to be excluded.