Comparison of optometrist glaucoma referrals against published guidelines

Abstract

Purpose: To examine if community optometrists follow published guidelines for referral of patients with suspect glaucoma to the hospital eye service. Methods: A retrospective audit of new optometrist-initiated referrals to the Glaucoma Service at Moorfields Eye Hospital, London was performed. Clinical data from referral letters recorded included evidence of intraocular pressure (IOP) measurement and tonometer used. Referral letter information was compared to 2009 guidelines published jointly by the College of Optometrists and Royal College of Ophthalmologists on referring glaucoma suspect patients. Results: A total of 289 new patients were seen in the Glaucoma Service over a 6 week period from 4th January 2011; a 100% hospital record retrieval rate was obtained. Of these, 114 (39%) were optometrists initiated referrals. Optometrist letters were available for 105 patients. IOP measurements were recorded in 102 (97%); most practitioners used non-contact tonometry (NCT; n = 69; 68%). Practitioners recorded <4 NCT readings per eye (4 readings: n = 3, 4%; 3 readings: n = 42, 61%; 2 readings: n = 6, 9%; 1 reading: n = 18, 26%). Seventy-seven patients (73%) reported with raised IOP as the main referral reason; of these, 33 (43%) were referred with raised IOP in isolation. NCT was the instrument used in the majority of these raised IOP cases (n = 56; 73%). In cases where raised IOP in isolation was the referral reason, 24 (73%) were recorded using NCT; 10 (30%) provided repeat IOP measurement data in the letter. One hundred and two (97%) referred patients attended the hospital appointment. Thirty (29%) were deemed not to have glaucoma, with the remainder diagnosed with ocular hypertension (n = 25; 25%), glaucoma suspect/glaucoma (n = 35, 34%) or narrow angles requiring intervention (n = 12, 12%). Thirty of the 33 patients referred with raised IOP in isolation attended their hospital visit. Ten (33%) of these patients were subsequently discharged. Six (20%) patients had IOP within normal limits when measured with applanation tonometry; all of these patients were kept within the service. Conclusions: Community optometrists using NCT for measurement should be reminded of the guidelines on number of readings to take and also the value of repeating NCT measures when appropriate. This may help to increase the accuracy of glaucoma suspect referrals to hospital eye service.

A collaborative care pathway for patients with suspected angle closure glaucoma spectrum disease

“…Multinomial logistic regression analysis highlighted the importance of having the angle appearance noted in the referral letter as part of the triaging process. A significant proportion of angle closure disease cases were misdiagnosed as open angle glaucoma disease in the Pre and Post Suite groups, similar to the study of Khan et al The rates of occludable angles requiring referral in lieu of routine open angle glaucoma disease management was notably higher than that found by Bourne et al and by Varma et al, but were lower than that in the study of Seider et al in a Chinese‐American population. This was likely due to a combination of the difference in patient cohort, threshold for referrals and the clinician group that was studied.…”

“…In comparison, the triaging system of Angle Suites, increased the hit rate for angle closure disease diagnosis to 70.1 per cent, with the additional benefit of decreasing waiting times to appointment. Previous studies have shown that more comprehensive referral letter content assists in the triaging process …”

“…Proformas for referrals stipulating a checklist may also be useful . Depending on the expected proportion of angle closure glaucoma within all cases of glaucoma seen within the community, the failure to distinguish the two by simply noting angle status may present a significant problem in community optometry, as noted by previous studies . A glaucoma‐specific electronic patient record form has been recently suggested .…”

The impact of SIGN glaucoma guidelines on false-positive referrals from community optometrists in Central Scotland

“…Contrast this to the report from England by Khan et al where only 71% had visual field assessments and only 27% were attached with the referral 25. Despite this, the proportion of referrals having repeat visual field testing was still only 42.8% post-SIGN 144.…”

How nice is NICE?

“…Criteria for diagnosis had been selectively extracted from diagnosis and management and transplanted across into primary care case-finding settings by a group of influential optometric organisations. Hasty and ill considered advice to their optometric members4 produced an ongoing problem of unnecessary flooding of NHS glaucoma services, with false positive referrals frequently based on poor quality intraocular pressure (IOP) measurements 5 6. In view of this unfortunate development, a legitimate question could be whether this problem might have been anticipated and avoided.…”