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

Optometric Management of Cataract Px

Prevalence

• Increases with age. Approaches 100% if lens opacities are included
• Patient defines whether it's visually significant

Risk Factors

• Exposure to UV light
• Smoking
• Heavy drinking
• Family/Genetic
• Race (higher in indian population)

Vision in Cataract

• Decreased light transmission of short wavelength light esp if the cataract is nuclear
• Refractive change - myopic shift, cyl changes
• Light scatter - glare, decreased contrast sensitivity, decreased VA

Management Pathway

• Px attends optom, cataract diagnosed and discussed, risks and benefits of surgery discussed. Px wishes to proceed and info given. Px offered choice of hospital and appointment agreed
• Px attends HES outpatient appointment w/ophthalmologist, pre-assessment w/nurse, date for surgery arranged/agreed. Details of current medication received from the optom/GP/Px
• Patient attends HES and day case surgery undertaken
• Patient attends HES or optom for final check, sight test. Px discharged or 2nd eye discussed and appt arranged
  

Optometric Management of Low Vision Px

Current Management

• Optoms are trained and qualified & NHS pays (usually in hospitals only)
• Low Vision shared care pays for community based Low Vision

Proposed Pathway

• START: Px referred to LV service from secondary care, GP, social worker, rehab officer, community nurse, occupational therapist, self referral. Px may have RVI, LVI, CVI. All px contacted by LVS within 10 days
• Px attends LVS - service seamless across health, social care and voluntary sector. Full sight test forms part of assessment. Px given info on eye condition, entitlements etc as well as local services. Counselling and advice on employment/education available. LVAs, advice and home adaptation discussed and made available. Referral to other areas of health and social care as needed. This includes certification.
• Px has followup visits as needed that may take place in home or elsewhere
  

Optometric Management of ARMD

Prevalence

• 350,000-500,000 in the uk 'blind' from ARMD
• Most of the impairment is due to wet ARMD
• Most of that is untreatable

Incidence

• 21,000 new cases every year
• 10% added risk/year to fellow eye

Non modifiable Risk Factors

• Age
• Genetic predisp
• Gender (females 2xrisk)
• Race
• Iris colour (light pig)
• Type I diabetes
• Rx
• Cataract (can vary w/UV exposure)
• Handgrip strength ('weak' px)
• OD appearance
• Size @ birth

Modifiable Risk Factors

• Smoking
• Drink
• Socioeconomic factors
• Nutrition
• Body Mass Index
• Dietary Fat Intake
• CV disease
• Hypertension
• No statin usage (if you have cholesterol more likely to get it)
• Aspirin
• Type II diabetes
• Sunlight exposure
• Birth of child (px weaked if had 5 or 6 kids)

Optometric Assessment of the ARMD Px

• History - co-morbidity; hypertension, diabetes, hyper cholesterol, smoking, excessive alcohol
• Acuity - If poss use logMAR - more immediate steps so can spot disease early
• Contrast sensitivity
• Amsler - History of metamorphopsia, give copy to put on fridge
• Refraction
• Dilated assessment w/Volk lens
• Decisions - if WET refer. Will see vasc changes, exudate, haem, oedema, neovasc
• Decisions - if DRY monitor especially if they have large confluent drusen

Medical Management of the ARMD Px

• Flu Ang exam to clarify/make diag of wet/dry
• Treat: Laser Photocoagulation - leakage away from the fovea
• Treat: Anti VEGF treatment - intraocular injection which blocks neovasc and causes shrinkage of existing vessels
• Macular translocation - surgery for ppl w/huge scars
• Future: retinal implants. Currently only for ppl who are totally blind
  

Optometric Management of DR

History

• before insulin DR wasn't recognised and insulin dependent diabetics died early. Type II were diet controlled
• 1950s-1970s diabetes becomes a controlled disease and DR was recognised. Hypoxia was recognised as the trigger for the neovascular process
• Laser treatment - pan retinal photocoagulation - focal treatment to stop specific leaks
• Newest development c.2000 - intensive diabetic control via continuous control, slow release insulin, insulin pumps

There were two big trials

1. Diabetes control and complications trial - type I diabetes (insulin cells destroyed)
   
2. UK prospective diabetes study - type II diabetes (high blood glu, relative insulin def)

Glucose tests for diabetes

• Fasting blood sugar = >7.8mmol/litre
• Random blood sugar = >11.1mmol/litre
• Two hour post load = >11.1mmol/litre = you're diabetic
• Two hour post load = >7.8mmol/litre = you have impaired glucose tolerance

Glycosylated Haemoglobin = Glu bound to haemoglobin. Measuring it is good because it correlates w/blood sugar average over 6-8 weeks:

• Normal <6% (corr w/ 7.6mmol/l)
  
• Controlled diabetic = 9% (corr w/10mmol/l)
  
• Intensive control = <7%>

If you're intensively controlled then there's only a 7% chance of you developing DR after nine years and if you're 9% controlled then it's around 20%. So intense control is way beneficial.

Initial Adverse Effects - sudden intensive control leads to increased DR in 6/9 months. Phase it in!

Factors which aggravate DR

• smoking
  
• hypertension
• hyperlipidaemia
• obesity
• renal disease
• pregnancy
• puberty

The challenge currently is to get 100% of diabetics an annual eye exam w/high level of accuracy (or every 6 mths for the high risk people) Strategies for screening include

• GP w/ophthalmoscope - good recruitment but poorest accuracy
• Special screenings + photo
• Optom - good accuracy but poorest recruitment. Optom has skill, equipment, accuracy and knowledge

Scottish National Screening Program

• Want to detect referable sight threatening retinopathy to reduce the risk of sight loss
• To detect lesser degrees of DR

This was launched April 2002. Target px were everyone >12yrs old, both type I and II, excluding everyone that already has ophth. care, the irreversibly blind and the medically untreatable. Working out national register of all diabetics, system of appts/feedback/followup. The whole thing is audited and coordinated

Screening process

1. Digital camera - 80% can have non-dilated. Pic stored for analysis
2. Digital photo w/mydriatics
3. Volk

Photos are then graded by technicians or optoms

The importance of screening must be stressed to ppl. Remember tell em not to drive after mydriasis/light sensitivity

Results

• Retinopathy yes/no?
• Follow-up (screen or referral)
• GP and ophthalmologist informed

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.

Referrals in Optometry

The quality of yr referral letters is a major determinant of your REP as well as being crucial for effective px care and to your reputation in the community.

As well as the referral letter other stuff that comes under referral includes verbal and written communications with the patient and other health care profs allowing transfer of care based on your examination. The referral letters need to be complete, accurate and useful (clear concise and understood)

Info for the Px (verbal or written - both if poss)

• Reason for referral - diag, risk - "the pressure in your eye is a bit high so you might have glaucoma". Use technical term and description
• Expected Management - when, who, what
• Appropriate time course - when expected/followup, what to do if followup is missed

Info for the professional

• Who is the patient - complete identification and contact deets - phone no. important if it's urgent
• Reason for ref - heading Re: , the key points, complete and concise relevant supporting info. brief history and test results if relevant. GOS18
• Identify Yourself - Name, posn, tel no, supervisor if pre-reg, stamp (esp if locum)
• What you expect/plan to do - recall/monitor/await discharge from hopital
• Authorisation - was verbal, signature best

Types of ref. out

• direct referral / shared care scheme
• ref to consultant via GP
• ref to optoms who specialize (keratoconus)

Ref Stats - How Well We Are Doin'

• 2.5% optoms no name on letter, 6% no postcode
• eg glaucoma - 85% give disc app, iop, field plot. which is good
• 80% good on the routine info - VA, refraction, symptoms, poor info on previous VA, fundus info, media, onset and duration of symptoms
• 57% no legible name, no practice address 7%

Types of referral "in"

• Individual professionals - optoms, GPs, Other health care providers - health visiting nurses, physios, occupational therapists
• Screening programs - schools, special needs
• Informal - patient referrals (cos of your good rep - build the good rep and acknowledge this stuff!)
  

Formal Co-Management Schemes

Currently in the uk there are around

• >65 diabetic schemes
• >35 cataract
• >20 glaucoma/ocular hypertension
• 13 low vision
• 10 referral/prioritisation

There are also some broad schemes like the one on the south side of Glasgow.

The Crown Report of 1999 recommended optoms as independent prescribers. The govt decided that supplemental prescriber status would come first. The New Prescribing Advisory Commitees drafted the legislation for that stuff in 2000, including a drug list, specific training and associated ongoing CET.

The New(est) Optom Legislation

• In 2005 the prescribage became no longer confined to 'in an emergency'. Also the drug list was updated
• Section 60 Order: student registration is now required, new registration for misconduct, new requirement for malpractice insurance, CL supplies regulated, optometric specialities defined, CET requirement
• Supplementary Prescriber - this involves a voluntary association with an independent prescriber (w/medical qual) managing cases according to set management plans
• Independent Prescriber - establishes diagnosis, directs clinical management and is responsible for prescribing

The NHS goals for co-management are as follows:

• Shorter waiting lists, greater px accessibility and more efficient use of the hospital eye services and the consultants

The benefits to optometry are thisssss

• Px continuity and advancement of the profession mainly - more variety, interest
• Increased REP
• Income to a certain (small) extent
  

Co Management / Shared Care Intro

Optoms should have an in-depth knowledge of diseases that are the focus of current co-management schemes, the necessary skills required for the schemes and understanding of their current state in UK optometry

There was a change in how shared care related to optometrists in the year 2000. Before then it only involved the optician spotting an injury/disease of the eye and referring the person to a medical practitioner. In 2000 the GOC put forward the following:

If in the pro. judgement of a registered optician there is no justification to refer a person consulting him to a registered medical practitioner the registered optician may at his discretion decide not to refer that person but in that event:

• He shall record a sufficient description of the injury or disease in his records
• his reason for not referring
• details of advice tendered
• if appropriate and with the consent of the px inform the GP

Legal posn - The NHS (General ophthalmic services amended 1986)

Optom having accepted persuant to the regs an application for the testing of sight make such examination of the patient's eyes as may be required and in doing so exercise proper care and attention. Where a contractor is of the opinion that a patient whose sight he has tested

• Shows on examination signs of injury or disease in an eye or in its immediate vicinity or any other abnormality of the eye or the rest of the visual system which may require medical treatment
• If px not likely to attain a satisfactory standard of vision notwithstanding the application of corrective lenses he shall so inform the px's doctor

Optoms have always been involved in px management, they are actually often the initial point of contact for a patient in the community. There are four levels of management which the optom is involved in

1. Detection with non-specific referral of the abnormality. This is like basic entry level!
2. Detection with informed referral for advice/management - this is where you're indicating diag/diff diag with maybe some signs and symptoms, level of urgency, suggest what will be done/who will do it. Ideally this is what you're aiming for. Doing (1) is just weak mang. Acceptable, but weak.
3. Detection w/a directed management plan in which you (a) advise the GP of the status of an ocular condition that you plan to monitor - diagnosis/plan or (b) advise the GP of an ocular condition and provide prioritized referral advice - w/diagnosis/plan, referral pathway and urgency and a note of where you participate in the scheme (maybe later on - like post cataract check)
4. Formal Shared Care Scheme - this is set up thru the health board/NHS and involves specific training, criteria for px inclusion, examination requirements and criteria for referral and monitoring. This can include delegation of medical management to the optometrist