Purpose This study assessed the role of specialist optometrists who were working in the community and sharing the care for glaucoma patients with, and under close supervision of, a consultant ophthalmologist working in the Hospital Eye Services (HES) to ensure high-quality standards, safety, and care. Methods From February 2005 onwards, the majority of all new glaucoma referrals to our eye department were diverted to our specialist optometrists in glaucoma (SOGs) in their own community practices. Selected patients in the HES setting who were already diagnosed with stable glaucoma were also transferred to the SOGs. The completed clinical finding details of the SOGs, including fundus photographs and Humphrey visual field tests, were scrutinised by the project lead.

The SOG scheme demonstrates acceptable levels of accuracy between SOG and glaucoma consultant. This scheme allows many stable low-risk patients to remain out of hospital eye department outpatient clinics.

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Conclusions Our data suggest that the DSAEK stroma may have a causative role in generating immune responses, that is, rejections seem to be favored by graft proximity to the AC angle. It may contribute to the migration of donor-derived antigen presenting cells (APCs) into the recipient's lymphatics (direct pathway). Alternatively, access to the graft of recipient APCs may be promoted by decentered graft positioning (indirect pathway). Interestingly, cells infiltrating the anterior chamber (AC) belong to the innate immune system: the cellular infiltrate contains mainly monocytes and cells differentiating into APCs, that is, mainly macrophages. 6 These cells can also be found in the cornea-but as an intact Descemet membrane does not allow any cellular transmigration, it is widely believed, that cells in AC are recruited through iris vessels and ciliary body in the context of a breakdown of the immune privilege. Cells in the corneal stroma (eg, after DSAEK) or the exchange of allo-antigens through APCs coming from the AC and/or the AC angle (especially after DMEK, where there are no donor stromal APCs present) consequently must be crucial for the generation of an immune response. In summary, the data may indicate an active role of donor-derived immune cells in the rejection process. Major limitation of our work is the size of the cohort; the importance of graft centration in DSAEK to minimize the risk for graft rejection therefore needs to be confirmed in a larger clinical setting.