GUEST EDITORIAL

Glaucoma and optometry: recognition, challenges andopportunitiesApproximately 10% of registrations for blindness in the UKare attributed to glaucoma and �2% of people older than40 years have chronic open angle glaucoma (COAG), a preva-lence increasing to �10% in people older than 75 years of age.The optometric profession plays a fundamental role in glau-coma detection, and has done so for several decades, initiatingreferral in excess of 90% of the glaucoma related referralsdirected to the HES.1 Despite the ongoing need for improve-ments in case finding, this important role merits recognition.Early referral surveys in the 1980s and 1990s highlighted alongstanding problem with the proportion of referrals deemedto be false positives (with estimates ranging from �30–40%)and the rather variable use of supplementary testing, not leastvisual field ‘screening’.2–4 Despite these latter problems, itmight have been argued, even back then, that optometric casefinding was effective, not least set against the considerablechallenges of case detection in a primary care setting where theprevalence of the disease is relatively low (i.e. the scenariofaced by a community optometrist assessing a much greaterproportion of non-glaucomatous individuals than their oph-thalmic counterparts in secondary care). In the former primarycare scenario, even when combining the traditional ‘triad’ ofdetection tests to maximise sensitivity and specificity, the rela-tively low glaucoma prevalence makes the resultant predictivepower of positive testing low also.5 Optometry found itselfbeing the profession responsible for glaucoma case detection,as the expectations placed upon the GOS regulation eye exami-nation grew alongside the increasing availability of tonometryand visual field testing, complimenting the longstanding (andmandatory) internal eye examination. While many of thoseworking in secondary ophthalmic eye care settings would havehad a very good appreciation of their primary care colleagues’problems with case detection (i.e. the relatively low prevalenceof glaucoma, the limited diagnostic accuracy of tests, and thedifficulties of implementing unfunded supplementary tests),this awareness may not always have been universally so.

Times have changed and so too services. In this issue ofOPO, the paper by Myint et al.6 describes the findings from alarge scale survey of the reported use of diagnostic tests forglaucoma by community optometrists. While the authors doacknowledge possible biases in their survey (not least the dis-crepancy between self-reported practices and actual practiceswith respect to ‘discretionary’ tests) and highlight the lack ofstandardisation with respect to equipment used, they are ableto conclude that UK optometrists are well equipped to carryout case finding for glaucoma. The high proportion of respon-dents making use of non-contact tonometry, the variableapproach to the method of optic disc assessment (despite theapparent shift towards more regular use of binocular indirecttechniques) and the wide range of perimeters used (anddoubtless test strategies and protocols for use too), all high-light the benefit of a standardised approach to assessment thatcan arise through implementation of an enhanced service using

trained and accredited community optometrists, althoughMyint et al.6 rightly raise the question of cost-effectiveness ofsuch services. In this regard, the inclusion in this issue of OPOof the paper by Parkins and Edgar7 is most prescient, withtheir analysis showing substantial cost benefit for a primarycare repeat measures scheme, albeit only minimal cost benefitis demonstrated for a referral refinement pathway involvingaccredited community optometrists. Different schemes maywell incur different costs, but it is clear that there is a pressingneed for further, more formal health economic evaluations ofenhanced schemes to inform future service developments,despite all the prima facie reasons that might be offered insupport of their development. Formal Glaucoma ReferralRefinement (GRR) has been in operation in some areas formore than 10 years. For example, the Manchester GRR schemewas established in 2000 with the primary aim of reducing thenumber of false-positive referrals to the HES.8 Subsequently,the Department of Health’s National Eye Care Services Steer-ing Group (glaucoma sub-group) described the concept ofcommunity referral refinement in 2002. The Manchesterscheme has been successful in reducing the false positive rateof referrals for suspect glaucoma from �40% to �11%. Thefalse negative rate is not known and merits investigation,although is not believed to have been a concern in the lifetimeof the scheme to date. Similarly, in Scotland, Ang et al.9 havereported on a retrospective study comparing referrals and HESnotes for two six-month periods before and after the new GOScontract was implemented. After the introduction of the newGOS contract, they found a significant increase in true positivereferrals, a decrease in false positive referrals, an increase inthe number of referrals with information on Goldmann Appla-nation Tonometry (GAT), dilated fundus examination andrepeat visual fields. There would, however, appear to be scopefor further improvement, since the post-implementation surveywas shortly after the introduction of the new contract and sig-nificant training has been provided and undertaken since;however, in so far as glaucoma is concerned, the more genericenhancement of the GOS north of the border appears to beoffering much the same as GRR schemes south of the border,but without the limitations of this enhanced service being con-dition specific. What GRR does not do, however, nor too forthat matter the enhanced GOS in Scotland, is reduce the bur-den of undetected disease, because in either case the enhancedservices are largely directed towards improving the case findingprocess for those already presenting to primary care. Burret al.10 undertook a systematic review and economic evaluationin relation to screening for open angle glaucoma and con-cluded that while population screening is not cost-effective,the targeted screening of high risk groups (by definition, witha higher prevalence) may be. They also draw attention to theneed for improving attendance for eye examinations and pro-posed a randomised controlled trial of interventions toimprove the uptake of screening. Most epidemiological surveys

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have tended to find that approximately 50% of glaucoma isundetected,11 with some surveys suggesting this figure may behigher. Herein resides a considerable challenge for publichealth, for the research community, for ophthalmic healthcarepractitioners (not least optometrists), and for the various pro-fessional bodies and those responsible for GOS developments,albeit the GOS is only one mechanism through which thisproblem might be addressed.

The 2009 introduction of the NICE guideline12 on the diag-nosis and management of chronic open angle glaucoma(COAG) and ocular hypertension (OHT), while not case find-ing and referral related in respect of recommendations, hashad significant consequences for referral. The requirementwithin the NICE guideline for patients with OHT to be‘offered’ further diagnostic testing including pachymetry andgonioscopy, and the subsequent recommendations made bythe Association of Optometrists about referral, has increasedthe proportion of new referrals for OHT and suspected COAG.In this issue of OPO, Shah and Murdoch13 report a risingnumber of referrals for OHT and suspect glaucoma (a findingalso supported by a referral ‘behaviour’ survey by Edgaret al.14) but an unchanged absolute number of glaucoma andglaucoma suspects identified, with a commensurate fall in thepredictive power of positive testing. While conceding that theNICE guideline excludes case finding and screening, theseauthors question ‘what advantage in improved case detectionthis represents’ and whether this is a cost effective strategy.The NICE guideline is, as stated above, a guideline about diag-nosis and management, with implications for case finding andreferral, rather than a means by which the case finding processwas intended to improve. The timescale for implementation ofthe NICE guideline should permit alternative pathways for‘offering’ the relevant tests to be developed. As describedabove, there is evidence from enhanced services to date toshow that these pathways can alter the quality and outcome ofreferrals. Furthermore, efforts have been made through the col-laborative working of the joint Colleges’ group to deal withsome of the concerns surrounding the response to the NICEguideline. The joint Colleges’ guidance highlights that practi-tioners may consider not referring patients at low risk of sig-nificant visual field loss in their lifetime, for example, patientsaged 80 years and over with measured IOPs <26 mmHg withotherwise normal ocular examinations as well as patients aged65 years and over with IOPs of <25 mmHg and with otherwisenormal ocular examinations (i.e. normal discs, fields and vanHerick). These groups do not qualify for treatment under cur-rent NICE guidance and the joint Colleges recommend thatsuch patients may be advised that they should be reviewed bya community optometrist every 12 months. Vernon et al.15

have analysed the population based Bridlington Eye Assess-ment Project (BEAP) data to identify the percentage of thosepatients aged 65 years or older that might be referred by com-munity optometrists as OHT suspects in relation to the origi-nal AOP recommendation vs the joint Colleges’ guidance. Intheir population, 85 of 1643 people (5.2%) with visual fieldshad a GAT IOP >21 mmHg in either or both eyes. Withoutcentral corneal thickness (CCT) data, all 85 would be referredunder the original AOP recommendation, whereas 31 (1.9%)would be referred under the joint Colleges’ guidance. If CCT

were used to influence referral, 13 (0.8%) people would bereferred under the joint Colleges’ guidance, suggesting that ifcommunity optometrists use GAT and CCT, and follow thejoint Colleges’ guidelines for referral, referrals of OHT suspectsto secondary care could be reduced to a fifth of those underthe original AOP recommendation.

There is, therefore, evidence to suggest that solutions mightbe found to some of the concerns about the dual problems ofboth the rising number and the proportion of true positivereferrals. In the wider and intended context, the NICE guide-line is about the diagnosis and monitoring of patients withOHT, COAG and suspected COAG, the treatment of theseconditions, service provision, and provision of information forpatients. While the recently published NICE glaucoma qualitystandard16 makes specific reference to local agreements beingin place for GRR, the earlier 2009 guideline12 had specificallyidentified a role for optometrists beyond case finding anddetection, for example, in diagnosing OHT and suspect COAGand in the monitoring of glaucoma. These latter roles demanda specialist qualification (when not working under the supervi-sion of a consultant ophthalmologist) and relevant experience.Traditionally the College of Optometrists has offered a higherqualification in glaucoma that meets this requirement (theDiploma in Glaucoma) and while this higher qualification hasproved very popular relative to other qualifications within theCollege higher qualification portfolio, the provision of a sylla-bus and an examination but without support for training hasmeant that this qualification (and certificate B, on manage-ment, in particular) might be seen as inaccessible. A new andeducationally sound glaucoma curriculum offers the opportu-nity for formal course provision and examination relevant tothe different levels of optometric role proposed. One challengehere is to ensure that while accessibility to training opportuni-ties is increased, standards are maintained, such that any spe-cialist glaucoma higher qualifications continue to have thebacking of the Royal College of Ophthalmologists, a greatstrength of the present Diploma. A further challenge is toensure ‘relevant experience’ by way of an appropriate clinicalplacement – there is, after all, only so much that lectures, inwhatever format, can offer towards clinical competency. Thegood work of the joint Colleges in glaucoma-related issues todate might usefully be extended into securing improved accessto post-graduate clinical placement training opportunities,surely the key to gaining ‘relevant experience’ for those not sofortunate to work alongside ophthalmologists in the hospitalsetting.

This editorial began with an acknowledgement of the visualimpairment attributable to glaucoma and it is fitting to returnto this central issue to conclude. The paper by O’Colmainet al.17 in this issue of OPO reports a 31% downward trend inthe rate of blind registration attributable to glaucoma in Fifein the past decade compared to the previous decade. Withoutsuggesting causality, the authors argue that earlier presentation,refinements to the hospital glaucoma services and medical andsurgical advances all play a part in this improvement. Effectiveglaucoma services intending to prevent avoidable blindnessrequire successful integration of primary and secondary care,with the appropriate level of risk of patient being assessed bythe appropriate professional in the appropriate setting. This

Editorial R Harper

328 Ophthalmic & Physiological Optics 31 (2011) 327–329 ª 2011 The College of Optometrists

view appears to be supported by the publication of the qualitystandard in glaucoma which states:

The quality standard for glaucoma requires that servicesshould be commissioned from and coordinated across allrelevant agencies encompassing the whole glaucoma carepathway, including primary, secondary and social care.An integrated approach to provision of services is funda-mental to the delivery of high quality care to people withglaucoma.16

The present ‘detected’ glaucoma workload is considerableand there is significant progress needed in respect of the bur-den of undetected disease. Optometry deserves recognition forthe fundamental role that it has played in case finding to date.Challenges remain for optometry to engage in improvementsin this process through the opportunities afforded by enhancedservices, be they directed at those already presenting for casefinding, or potentially an increased role in dealing with theburden of undetected disease. At the same time, the last dec-ade has seen a growing interest in optometry providing care tothose already diagnosed with glaucoma, suspect glaucoma orOHT, and this role is one which is supported with the publi-cation of the NICE guideline. Contemporaneously, the avail-ability of independent prescribing and glaucoma specialistaccreditation create a sound platform from which further con-tributions can be made by optometry to the considerablecapacity problems that exist in the management of this largelychronic group of diseases.

Robert Harper1,2,3

1Manchester Royal Eye Hospital, 2Manchester Academic andHealth Science Centre, Central Manchester

University Hospitals NHS Foundation Trust, and3Faculty of Medicine and Human Sciences and

Faculty of Life Sciences (Optometry),University of Manchester,

Manchester, UKE-mail address: robert.harper@cmft.nhs.uk

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Robert Harper

Robert Harper is an Optometrist Consultant at the Manchester Royal Eye Hospital and Visiting SeniorLecturer within the Faculty of Medicine and Human Sciences and Faculty of Life Sciences (Optometry)at the University of Manchester.

R Harper Editorial

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