“Glaucoma care has the potential to form a big part of what we do"

I wear two hats when it comes to glaucoma services. I work a regular day a week as a specialist glaucoma optometrist in NHS hospital eye clinics, and in community optometry I help provide Glaucoma Repeat Readings and Enhanced Case Finding. We also have an Ocular Hypertension (OHT) monitoring service in Gloucestershire.

My hospital work is quite defined. I have a list of patients – generally they will have a work-up with a technician first with visual fields and optical coherence tomography, and then I see them for the clinical examination. These patients have been seen previously within the service and have an established clinical management plan. We’re working to ascertain if that clinical management plan is still appropriate, or if something needs to be changed.

In the community, the Glaucoma Repeat Readings and Enhanced Case Finding services have developed so that patients can be seen, who may otherwise have been referred if there wasn’t that step in primary care. A good proportion of patients are deflected through repeat readings, where either their pressures are normal on a Goldmann applanation tonometry reading, or the field defect that was detected in the original sight test isn’t repeatable.

 

The Enhanced Case Finding pathway is for cases where there are suspicions of glaucoma – changes to the optic nerve have been detected – and it allows you to have another look at things with a fresh pair of eyes to ascertain whether you agree with the original thought that they need to be referred, or that actually no, they don’t reach the threshold of concern.

The OHT monitoring service sees patients very much like those in the hospital clinics, but they have been risk stratified as a low enough risk to be discharged to the community. Here, you are looking to see if there is a change that suggests progression. If so, they are sent back into secondary care for an assessment to be made by a more senior colleague, or for the clinical management plan to be changed.

The mechanism is there for referrals between practices. Historically, there has been a bit of hesitation in the profession to send a patient to another practice. I think there may always be some barriers there, but cross referral is there to send a patient to a colleague with a specialism or who might be more confident in that area for a second opinion. I think that is really valuable and it shows a maturation of the profession.

Glaucoma services in the community mean some patients don’t need to be sent into the hospital in the first place, where they face the anxiety of waiting to find out if something is wrong. The services deflect patients from that, which I think is really important. It provides reassurance that though something might have been identified, on a second look it is not concerning and we can keep an eye on it.

Community monitoring allows patients to be seen closer to home, potentially by a practice they may already have an ongoing relationship with, and where they might know the optometrist well. It allows for a continuity of care which is really valued by patients but might not be available within the busy secondary care environment.

 

The potential is there to help reduce the backlog in secondary care. Within glaucoma services there are a lot of patients who, because of their low risk profile, could be managed appropriately by the right kind of services and people in the community. This allows secondary care to concentrate on the patients they need to be focusing on. This could be a definite quick-win for the new Government.

I think there could be an expansion of community optometry’s role in glaucoma services. Not necessarily in seeing more complex patients, because I think the complexity and risk must be managed appropriately, but there are good services that could be scaled up.

It is a chance for us to do something powerful and effective in patient care, and we should grab it with both hands

The workflow to ensure patients are seen at the right time, and that they don’t go longer between follow-ups than they should, needs to be looked at. This is a concern my community colleagues hear from glaucoma patients who come in for their sight test: ‘I was meant to be seen six months ago and I haven’t heard anything. What do I do?’

I think there is an opportunity for community optometry here. It needs everyone around the table to agree. It requires ensuring that any development is patient-centric and all for the benefit of the patients we are looking after.

I think this is an exciting opportunity for those optometrists who want to, to develop the kind of clinical care they are able to offer to patients. We should try and make the most of it, working with colleagues across the sector in developing that so we’re not missing the opportunity. It is a chance for us to do something powerful and effective in patient care, and we should grab it with both hands.

 

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A beginning, continued education, and placements

My involvement in glaucoma services began around 2007. I joined a project in Gloucester to create a pod clinic of four optometrists who would see glaucoma patients with overarching ophthalmologist supervision. This was based on similar work in the Forest of Dean.

The optometrists involved were required to have hospital experience first and so the four of us had a clinic once a month with a consultant. It was a steep learning curve, but it was really useful, giving us the opportunity to be exposed to hospital clinical. It also gave the consultant an appreciation of the community perspective.

The aim was that we would complete further qualifications in glaucoma to underpin our work and see patients in the community. Changes to the higher qualification meant that while we completed all the modules available to us at the time, because it hadn’t been ratified yet, we only got as far as the Professional Certification. I’m now completing my Higher Cert, nearly 10 years later. It’s probably the hardest thing I’ve had to do.

I would say a barrier to completing the Higher Cert and Professional Diploma in glaucoma is the clinical placement requirement. Compared to the independent prescriber (IP) placement, which is based around a number of clinics and being signed off with a logbook, the glaucoma qualifications stipulate the number of episodes required.

Ophthalmologists have a fellowship in their sub-specialism, so they might have a fellowship in glaucoma for six months or a year which forms one step on the ladder towards becoming a consultant. In an ideal world I think there should be a framework where optometrists can go out and do a set placement to get their Higher Cert or Diploma.

You do need the support of secondary care, or a provider of those services, to secure a placement and get the episode numbers. What has made it easier for me is that the course at Cardiff University allows for an optometrist with a diploma to supervise the clinic. I think that is a big step forward. It opens opportunities where the historical requirement for the supervisor to be an ophthalmologist was a barrier.