Evaluating and optimising glaucoma referral refinement pathways with specific reference to the changes scheme

Background: The Hospital Eye Service (HES) was receiving an unsustainable level of new referrals for suspected glaucoma, which was resulting in delays in clinic appointments. In an attempt to reduce the burden on the HES the concept of refining a referral from the high street optometrist was introduced. Glaucoma Referral Refinement schemes (GRRS) have proliferated across the country over the past decade, often demonstrating marked variation in pathway design, referral criteria as well as the level of specialist optometrist competency and training. Standardisation of GRRS through national policy is required. / Plan of Research: The investigations are focused around 6 parts. The first three parts address referral criteria of GRRS and the agreement between eye health professionals through a multi-site review of schemes in England. The next two parts look at the experience of care and the access to eye health in a GRRS. The last section builds upon the findings from the first three parts and focuses on safety and in particular the role of virtual review in these schemes. / Results: Specialist optometrists working within GRRS can reduce the proportion of patients discharged at the first visit in the HES. However overemphasis on intra-ocular pressure as a criterion for referral is having an adverse effect on detection of glaucomatous optic nerve features. Low-risk referrals are suitable for specialist optometrist review, with virtual review an effective extra safety measure. High-risk referrals should be reviewed directly in the HES. / Clinical Significance: GRRS is a safe and cost effective method of reviewing low-risk glaucoma referrals. This research can contribute evidence to help establish a national policy for both the referral criteria and the organisational set-up of GRRS in the UK

Impact of minimally invasive glaucoma surgery on the ocular surface and quality of life in patients with glaucoma

Background: Minimally invasive glaucoma procedures are emerging as clinically effective and safe glaucoma management approaches; however, evidence regarding quality-of-life outcomes is limited. / Objectives: To explore the impact of minimally invasive glaucoma surgery (MIGS) combined with phacoemulsification on patient-reported outcomes and clinical parameters related to ocular surface disease in people with glaucoma. / Design: Retrospective observational study. / Methods: Fifty-seven consecutive patients were examined prior to undergoing iStent combined with phacoemulsification with or without adjunctive endocyclophotocoagulation and at 4-month follow-up. / Results: At follow-up, on average patients returned statistically significantly improved scores on glaucoma-specific (GQL-15, p < 0.001; GSS, p < 0.001), general health (EQ-5D, p = 0.02) and ocular surface PROMs (OSDI, p = 0.001). Patients were using fewer eye drops on average after MIGS compared with before surgery (1.1 ± 0.9 versus 1.8 ± 0.8; p < 0.001). Undergoing MIGS was associated with improved tear film break-up time (p < 0.001) and reduced corneal fluorescein staining (p < 0.001). / Conclusion: This retrospective audit shows quality of life and clinical parameters related to the ocular surface are improved following MIGS combined with phacoemulsification in patients previously treated with anti-glaucoma therapy

The effectiveness of schemes that refine referrals between primary and secondary care - the UK experience with glaucoma referrals: the Health Innovation & Education Cluster (HIEC) Glaucoma Pathways Project

Objectives: A comparison of glaucoma referral refinement schemes (GRRS) in the UK during a time period of considerable change in national policy and guidance. Design: Retrospective multisite review. Setting: The outcomes of clinical examinations by optometrists with a specialist interest in glaucoma (OSIs) were compared with optometrists with no specialist interest in glaucoma (non-OSIs). Data from Huntingdon and Nottingham assessed non-OSI findings, while Manchester and Gloucestershire reviewed OSI findings. Participants: 1086 patients. 434 patients were from Huntingdon, 179 from Manchester, 204 from Gloucestershire and 269 from Nottingham. Results: The first-visit discharge rate (FVDR) for all time periods for OSIs was 14.1% compared with 36.1% from non-OSIs (difference 22%, CI 16.9% to 26.7%; p<0.001). The FVDR increased after the April 2009 National Institute for Health and Clinical Excellence (NICE) glaucoma guidelines compared with pre-NICE, which was particularly evident when pre-NICE was compared with the current practice time period (OSIs 6.2–17.2%, difference 11%, CI −24.7% to 4.3%; p=0.18, non-OSIs 29.2–43.9%, difference 14.7%, CI −27.8% to −0.30%; p=0.03). Elevated intraocular pressure (IOP) was the commonest reason for referral for OSIs and non-OSIs, 28.7% and 36.1%, respectively, of total referrals. The proportion of referrals for elevated IOP increased from 10.9% pre-NICE to 28.0% post-NICE for OSIs, and from 19% to 45.1% for non-OSIs. Conclusions: In terms of ‘demand management’, OSIs can reduce FVDR of patients reviewed in secondary care; however, in terms of ‘patient safety’ this study also shows that overemphasis on IOP as a criterion for referral is having an adverse effect on both the non-OSIs and indeed the OSIs ability to detect glaucomatous optic nerve features. It is recommended that referral letters from non-OSIs be stratified for risk, directing high-risk patients straight to secondary care, and low-risk patients to OSIs

Impact of optical coherence tomography on diagnostic decision-making by UK community optometrists: a clinical vignette study.

PURPOSE: In recent years, there has been widespread investment in imaging technologies by community optometrists in the UK, most notably optical coherence tomography (OCT). The aim of the current study was to determine the value of OCT in the diagnosis of posterior segment diseases in a representative sample of community optometrists using a clinical vignette methodology. METHODS: A group of community optometrists (n = 50) initially completed a standardised training package on OCT interpretation followed by a computer-based assessment featuring 52 clinical vignettes, containing images of healthy (n = 8) or glaucomatous (n = 18) discs or healthy (n = 8) or diseased (n = 18) fundi. Each vignette featured either a single fundus/disc photographic image, or a combination of a fundus/disc image with the corresponding OCT scan. An expert panel confirmed that the fundus images presented alone and those in combination with OCT data were of a similar level of difficulty and that the cases were typical of those seen in primary care. For each case, the optometrist selected their diagnosis from a pull-down list and reported their confidence in their decision using a 10-point Likert scale. Pairwise comparisons of the fundus image alone and fundus image/OCT combination were made for both diagnostic performance and confidence. RESULTS: The mean percentage of correct diagnoses using fundus imaging alone was 62% (95% CI 59-64%) and for the combination of fundus image/OCT was 80% (95% CI 77-82%). The mean false negative rate with fundus alone was 27% reducing to 13% with the OCT combination. Median confidence scores for fundus imaging alone was 8.0 (IQR 7.0-8.0) and 8.3 (IQR 8.0-9.0) for the combination. Improvements in performance and confidence were statistically significant (p < 0.001). CONCLUSION: The results from this vignette study suggests that OCT improves optometrists' diagnostic performance compared to fundus observation alone. These initial results suggest that OCT provides valuable additional data that could augment case-finding for glaucoma and retinal disease; however, further research is needed to assess its diagnostic performance in a routine clinical practice setting

The effect of trabeculectomy surgery on the central visual field in patients with glaucoma using microperimetry and optical coherence tomography

Purpose To determine the functional and structural effects of trabeculectomy surgery on patients with advanced glaucoma and central visual field defects in the early post-operative period. Methods Thirty consecutive adult subjects with advanced glaucoma requiring trabeculectomy surgery and an established visual field defect within 10° of fixation underwent microperimetry (MAIA MP-1, CenterVue, Padova, Italy) and optic disc optical coherence tomography (OCT) imaging (Spectralis, Heidelberg Engineering, Germany) pre-operatively, and 1 month and 3 months following trabeculectomy surgery. Main outcome measures were post-trabeculectomy change in mean threshold on microperimetry and nerve fibre layer thickness on OCT. Fellow eyes were used as controls. Results The mean change in MP average threshold values from pre-operative to post-operative was 0.6 ± 1.9 dB for treated eyes and 0.1 ± 1.3 dB for control eyes (p = 0.14) at 1 month and 0.2 ± 2.3 and −0.3 ± 1.6 dB at 3 months (p = 0.22). Mean change in global nerve fibre layer thickness was −0.6 and −0.5 µm for operated and control eyes, respectively (p = 0.83), at 1 month and 0.8 and −0.4 µm at 3 months (p = 0.88). The kappa agreement for structure–function correlation between OCT and MP was 0.735 (confidence interval 0.59–0.88) (p &lt; 0.005). Conclusions Central visual function and retinal nerve fibre layer thickness appear to be preserved in glaucoma patients with central visual field defects undergoing trabeculectomy surgery in the early post-operative period. These data may inform glaucoma surgeons considering trabeculectomy surgery in this patient group

Microperimetry and optical coherence tomography imaging in the fellow eye of patients with unilateral focal ischaemic glaucoma

Purpose To determine whether microperimetry or optical coherence tomography (OCT) imaging can detect early disease in the fellow eye of patients with unilateral focal ischaemic glaucoma. Methods Thirty-seven consecutive adult patients with unilateral focal ischaemic glaucoma with a unilateral split-fixation visual field defect on standard automated perimetry (SAP) with normal SAP in the fellow eye were selected. All patients underwent microperimetry (MAIA, CenterVue, Italy) of the central 10 degrees and OCT imaging (Spectralis, Heidelberg Engineering, Germany) of the retinal nerve fibre layer of both eyes. The main outcome measures were reduced retinal sensitivity on microperimetry and/or retinal nerve fibre layer thinning on OCT imaging of the fellow eye. Results Thirty fellow eyes had abnormal global thresholds on microperimetry, and 20 had abnormal OCT imaging studies. Kappa agreement between tests in fellow eyes was poor (p = 0.2546). Fixation was significantly poorer in fellow eyes on microperimetry when compared to eyes with glaucoma (p &lt; 0.003). In the fellow eyes that were abnormal, microperimetry identified reduced retinal sensitivity at fixation. Conclusion Microperimetry detects reduced retinal sensitivity close to fixation and OCT detects focal thinning of the retinal nerve fibre layer in the fellow eye of most patients with presumed unilateral focal ischaemic glaucoma. Further studies are required to correlate specific optic disc features on OCT imaging with microperimetry in the fellow eye of this patient group

The effect of trabeculectomy surgery on the central visual field in patients with glaucoma using microperimetry and optical coherence tomography

Purpose To determine the functional and structural effects of trabeculectomy surgery on patients with advanced glaucoma and central visual field defects in the early post-operative period. Methods Thirty consecutive adult subjects with advanced glaucoma requiring trabeculectomy surgery and an established visual field defect within 10° of fixation underwent microperimetry (MAIA MP-1, CenterVue, Padova, Italy) and optic disc optical coherence tomography (OCT) imaging (Spectralis, Heidelberg Engineering, Germany) pre-operatively, and 1 month and 3 months following trabeculectomy surgery. Main outcome measures were post-trabeculectomy change in mean threshold on microperimetry and nerve fibre layer thickness on OCT. Fellow eyes were used as controls. Results The mean change in MP average threshold values from pre-operative to post-operative was 0.6 ± 1.9 dB for treated eyes and 0.1 ± 1.3 dB for control eyes (p = 0.14) at 1 month and 0.2 ± 2.3 and −0.3 ± 1.6 dB at 3 months (p = 0.22). Mean change in global nerve fibre layer thickness was −0.6 and −0.5 µm for operated and control eyes, respectively (p = 0.83), at 1 month and 0.8 and −0.4 µm at 3 months (p = 0.88). The kappa agreement for structure–function correlation between OCT and MP was 0.735 (confidence interval 0.59–0.88) (p < 0.005). Conclusions Central visual function and retinal nerve fibre layer thickness appear to be preserved in glaucoma patients with central visual field defects undergoing trabeculectomy surgery in the early post-operative period. These data may inform glaucoma surgeons considering trabeculectomy surgery in this patient group