Patients referred after the introduction of SIGN guidelines were 33.5% less likely to be discharged at the first visit. Although compliance to most recommendations in SIGN guidelines has improved, there is still a need to improve adherence to referral criteria.
Aim: To examine the accuracy of referrals by community optometrists for suspected primary angle closure, including primary angle closure suspects, primary angle closure and primary angle closure glaucoma. Methods: A retrospective review of 769 consecutive patients referred by community optometrists to the glaucoma clinic at a university hospital in Scotland. Ninety-five of 715 eligible subjects (13%) were referred due to suspected angle closure. All subjects had a comprehensive eye examination in the glaucoma clinic, including gonioscopy, with angle closure defined according to the International Society of Geographical and Epidemiological Ophthalmology classification as iridotrabecular contact over at least 270 degrees. Results: Fifty-nine of 95 subjects referred due to suspected angle closure were confirmed to have an occludable angle, while 36 of 95 (38%) had open angles (positive predictive value = 62%). Of 620 patients referred to the glaucoma clinic for reasons other than narrow angles, 601 (97%) had open angles on gonioscopy and 19 (3%) had narrow angles.Using the 620 patients referred with 'open angles' as a control group, sensitivity was estimated as 76% and specificity 94%. Eleven of 95 (12%) patients referred for possible angle closure were discharged at the first visit compared to 156 of 620 (25%) referred to the glaucoma clinic for other reasons (p = 0.003). In a multivariable model, suspect angle closure detected by the optometrist (OR = 56.0, 95% CI 35.2-89.2, p < 0.001) and female gender (OR = 1.9, 95% CI 1.2-3.1, p = 0.008) were associated with increased odds of angle closure on gonioscopy. Conclusion: Community optometrists had good ability to detect eyes at risk of angle closure. There was also greater accuracy of referrals for suspected angle closure than for other glaucoma referrals.
There was good overall agreement between CCT measured by community optometrists and measurements obtained in the glaucoma clinic. The tendency for thicker CCT measurements by community optometrists may be due to more peripheral or non-perpendicular positioning of the pachymeter relative to the cornea.
Fig 1. a) Computed tomography of the brain showing left orbital mass with infiltration of the left medial rectus. b) Magnetic resonance of the brain/orbit T2-weighted image showing the left orbital homogeneouslyenhancing mass with compression of the optic nerve.
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