Glaucoma Collaborative Care in Action

What is the role of the optometrist and ophthalmologist in managing glaucoma?

I think optometrists provide an essential service in glaucoma screening and detection, monitoring stable glaucoma and recognising indicators for early ophthalmology review, providing feedback on the treatment plan and outcomes, and patient education. Optometrists play a critical role in working closely with ophthalmologists to achieve targets and adjust treatments.

The role of the ophthalmologist is to confirm diagnosis and offer a spectrum of treatment options, formulate a tailored treatment plan, monitor outcomes and adjust the plan as needed, educate patients and the community, and continue research.

Both have a role in educating colleagues about glaucoma detection and management, and conducting research to improve best practice for glaucoma management.

Optometrists will play a greater role in the medical management of glaucoma

Q: What does best practice for glaucoma management look like?

While best practice changes with time, a system that provides patients with ready access to experts in glaucoma care in a way that is timely, geographically suitable and affordable, is what we aim for.

This is where collaborative care has many benefits as patients can access care within their local communities at short notice. This has more relevance for remote and regional communities, but is certainly applicable across the board.

The ultimate goal is that patients are only seen when there is a need, for example, for any changes to their condition, deteriorating intraocular pressure (IOP), medication intolerance and changes of this nature.

Q: If you had one key message to share with fellow ophthalmologists and optometrists about glaucoma, what would it be?

The key to successful collaborative care is communication between health providers. The optometrist and ophthalmologist working together require an open channel of communication and, in particular, need a clear understanding of each other’s roles, processes in place for managing issues when they arise, and confidence in each other’s abilities. If this breaks down, then patients potentially have unnecessary re-referral, or much worse, are not referred when they need to be, and the whole collaborative care model breaks down.

Q: What does the future of glaucoma management look like?

Artificial intelligence will play a greater role. It will potentially allow patients to monitor themselves at home and only be seen by their glaucoma specialist when needed, rather than at regular intervals.

Screening will improve – individuals will be able to use their smart phone to image their disc, measure their field, and calculate risk to determine need for further assessment.

There will be a shift toward patient centred outcomes. We will no longer measure success in terms of IOP reduction or change to visual fields, but rather quality of life scores.

There will be greater specialisation. Optometrists will play a greater role in the medical management of glaucoma. Ophthalmologists, who are glaucoma sub specialists, will concentrate more on the surgical management of glaucoma and find less mild to moderate glaucoma in their practice. They may work side by side with optometrists in dedicated glaucoma centres. General ophthalmologists may find they manage very little glaucoma as a result.

There will be a shift away from eye drops in favour of new modes of drug delivery. Minimally Invasive Glaucoma Surgery (MIGS) is already being used as an early surgical intervention and is here to stay.

Non-IOP treatment options will improve, targeting neuroprotection and neuroregeneration. Stem-cell interventions may be a possibility as well as the bionic eye for glaucoma related blindness. Genetics may be used to tailor treatment options or even initiate treatment prior to the disease manifesting.

COLLABORATIVE CARE: CASES THAT DO AND DON’T WORK

The Case of Mrs Dalby*

When 65 year old Mrs Dalby was diagnosed with glaucoma, she advised her optometrist that attending the ophthalmologist would be too expensive.

In response, the optometrist offered to manage her glaucoma, and because she was not therapeutically endorsed, arranged for Mrs Dalby’s general practitioner to prescribe prostaglandin monotherapy eye drops on request.

Mrs Dalby was seen at six monthly intervals. Her pressures were monitored with non-contact tonometry and she was always told her results were “OK”. Visual fields and optic nerve OCT were also performed, however results were not advised. After three years of management, Mrs Dalby noticed some declining vision and independently sought a second opinion in a public glaucoma outpatient clinic.

Results from the glaucoma outpatient clinic showed Mrs Dalby’s IOPs, while on prostaglandin monotherapy, were fairly high at 20mmHg (right eye). She also displayed a well below average central corneal thickness of 450 microns. Unfortunately, in the context of these findings, her assessment also showed advanced glaucomatous optic neuropathy, causing a right tunnel vision scotoma and left superior hemi-field defect. Mrs Dalby required glaucoma filtration surgery in both eyes to reduce any further glaucoma progression.

In this case, collaborative care involving only the general practitioner and a non-therapeutically endorsed optometrist, may have limited knowledge and access to other therapeutic agents. A failure to recognise that Mrs Dalby’s glaucoma was uncontrolled meant treatment was not escalated appropriately. Had an ophthalmologist been involved in the early stage of her management, when visual field and OCT results first indicated progression of glaucoma and loss of vision, Mrs Dalby’s vision may have been saved.

The Case of Mrs Jones*

Seventy year old Mrs Jones has glaucoma and lives in a remote country town where access to healthcare is challenging. Her nearest general ophthalmologist is 100km from her home, and only visits the town centre once a month.

When regular testing indicated that, despite her strict compliance, Mrs Jones’ therapeutic management for her glaucoma had been unsuccessful, she was referred to a subspecialty glaucoma ophthalmologist in Sydney.

It was determined that Mrs Jones needed trabeculectomy surgery to manage her glaucoma. By necessity, the surgery had to take place in Sydney, however to minimise the burden of attending follow up appointments, a collaborative care arrangement was established.

Mrs Jones’ care plan involved her local optometrist, who performed IOP testing and provided an overall assessment at least once a week, and maintained constant contact with her general ophthalmologist and glaucoma ophthalmologist. City visits were maintained but minimised.

Mrs Jones recovered from surgery and returned to a normal interval of glaucoma surveillance, which was shared between the general ophthalmologist and optometrist in her local region.

In Mrs Jones’ case, sight saving interventions were possible thanks to a close knit health care team.

CASE LEARNINGS

These two cases demonstrate that successful collaborative management of glaucoma patients requires:

• A clear understanding of each health care professional’s roles and expectations regarding a patient’s care,
• The ability for health care practitioners to identify when a patient requires a referral for early intervention, and to seek escalation of care if there is uncertainty in any clinical findings,
• The ability for health care professionals to communicate clearly, and
• Alignment of all involved healthcare professionals across a patient’s clinical findings, such as their target IOP and any future overall management plans.

* Names have been changed for patient anonymity.

Margaret Lam practises full scope optometry, and has a passionate interest in contact lenses, retail aspects of optometry, and successful patient communication and management. She has extensive experience in specialty contact lens fitting in corneal ectasia, keratoconus and orthokeratology, and is a past recipient of the Neville Fulthorpe Award for Clinical Excellence.

Ms Lam is the National President of the Cornea and Contact Lens Society of Australia and is a National Advisor on the Optometry Australia Board. She teaches at the School of Optometry at UNSW as an Adjunct Senior Lecturer and works as the Head of Professional Services for George and Matilda Eyecare.

Dr Colin Clement is an ophthalmologist with expertise managing cataract and glaucoma. He is a staff specialist at Sydney Eye Hospital, a clinical senior lecturer at Sydney University and is director of glaucoma surgical wet lab training at the Sight Foundation Theatres (Sydney). Dr Clement has combined his passion for surgery and teaching to develop training courses on non-penetrating glaucoma surgery and minimally invasive glaucoma surgery that have been run across Australia and New Zealand. He is the author of more than 50 research articles, six book chapters and is the co-editor of a textbook on glaucoma.