Glaucoma Referral Refinement & OHT Monitoring

LOCSU has developed  care pathways for glaucoma referral refinement, OHT monitoring and ocular hypertension diagnosis.

The aim of the pathways is to reduce unnecessary referrals to the hospital eye service; reduce patient anxiety and increase capacity within the overburdened hospital glaucoma clinics. This will privide a more cost effective service with a greater number of patients being managed within the primary care setting. This has been shown in the North East of Scotland and in Manchester, where there has been a reduction in false positive referrals of 40%.

The referral refinement pathway would allow accredited optometrists to repeat diagnostic tests to confirm the risk of disease, and thus improve the accuracy of referrals and deflect unnecessary referrals. The service would also allow diagnosis of ocular hypertension (OHT) and suspect chronic open angle glaucoma (COAG) by accredited optometrists, retaining more patients in primary care.

The aim of an OHT and suspect COAG monitoring pathway is to reduce the number of secondary care consultations for the cohort of patients who are diagnosed either as having OHT i.e. consistently high intra-ocular pressures (IOPs) but no glaucoma, or as being COAG suspect i.e. normal IOP but other suspicious signs. Currently, patients considered to have a greater chance of developing COAG due to elevated IOP or other suspicious signs are generally retained in secondary care and reviewed there on an annual basis, following referral in. The new service would provide for these patients to be discharged back into primary care for monitoring by community optometrists. Patients would only be referred back into secondary care if there was a change in clinical status.

Updated Glaucoma/OHT pathways  and    powerpoint presentation following publication of NICE Glaucoma Guidelines

LOCSU has updated its glaucoma/OHT package of support, following  the publication of the NICE  guidelines on glaucoma ensuring that there is no contradiction between the requirements of NICE and the  pathways themselves. Please click  on the pdf document to the right of your screen for a copy of the pathway.

LOCSU launched a revised pathway for Intraocular Pressure (IOP) Refinement in June 2010 to incorporate joint advice issued by the Royal College of Opthalmologists and the College of Optometrists on referrals for patients with raised intraocular pressure (the updated pathway also contains helpful guidance on training and accreditation).   There are specific groups of patients who are considered by NICE as having a low risk of developing visual field loss in their lifetime and the joint guidance advises that practitioners may choose to not refer patients in these groups assuming all other aspects of the eye examination are normal.   It is important that the assessment of whether a patient falls into one of the identified low risk groups is based on accurate IOP measurements; therefore IOP refinement with Goldmann (or Perkins) applanation tonometry is necessary before a decision on the need to refer can be made.

New enhanced services based on the LOCSU pathways have been commissioned by several PCT areas and there are many more PCTs in advanced stages of discussion with their LOCs regarding local implementation of these pathways.   Trevor Warburton (Chairman of LOCSU's Clinical Advisory Group) said that early results from areas that have implemented refinement of pressure readings (Level 1a) showed that referrals were reduced by well in excess of 50% so the economic argument for refinement was unassailable.   Cindy Tromans, College President and Chairman of the Joint College of Optometrists/Royal College of Opthalmologists Joint Glaucoma Guideline Group said that the Joint Colleges' Glaucoma Guideline Group welcomed the publication of the updated LOCSU Referral Refinement Pathway, which reflected the Joint Guidance.   She said that the new pathway would make a significant contribution to the reduction of false positive referrals to the Hospital Eye Service and maximise the service that community optometrists and the Hospital Eye Service can deliver to the public.

LOCSU has also updated its powerpoint presentation, complete with briefing notes, which can be used to explain the glaucoma care pathway to commissioners and to open up discussions on developing an enhanced glaucoma service in your area. Please contact LOCSU  to discuss how we can help you to develop a business case    and to work    towards getting    the pathway commissioned in your area.    

NICE Glaucoma Referral Guidelines  

The NICE guidelines, published in April 2009,    provide a framework for the diagnosis and management of chronic open angle glaucoma (COAG) and ocular hypertension (OHT) in England and Wales. The guidelines require that OHT should ber formally diagnosed using gonioscopy before continued monitoring; OHT is defined in the guidance as intraocular pressure over 21 mm Hg.

To read the NICE guidelines themselves, please click here.

The AOP, ABDO and FODO strongly advise optometrists to take note of the NICE Guidelines when considering the referral of patients with signs of OHT.   To access  the joint advice  from these bodies, please click here