Implementation of optical coherence tomography (OCT) imaging for every patient, and a clear process for eye examinations, has potential to shift undiagnosed glaucoma from 50% to around 35% of patients, and increase detection of age related macular degeneration (AMD) in its early stages, according to Peter Larsen, Honorary Principal Investigator of the Health Services Unit at Centre for Eye Research Australia (CERA) and Vice President, Business Development for Topcon Healthcare Solutions.
In his prior role as Specsavers Optometry Director Australia and New Zealand (ANZ) Mr Larsen initiated an entirely new model of care within the Specsavers Group, centred on clinical informatics, which is increasingly acknowledged for driving improved health outcomes.
In a presentation to ophthalmologists at a Royal Australian and New Zealand College of Ophthalmologists (RANZCO) Victoria branch conference, Mr Larsen reported on big data analysis of one million eye exams performed over six months in Specsavers stores with and without OCT.
“There is strong evidence that without clinical benchmarking and OCT, optometrists were missing 50% of suspects based on expected glaucoma prevalence in the community,” said Mr Larsen. “Once we introduced a standardised technology led approach, this number significantly improved”.
INDEPENDENT OPTOMETRY CONCURS
Independent optometrists Zahn Kidson (Sippy Downs Queensland) and Julia Deuel (Eyedentity Optometrists Victoria) have been using OCT for several years, and both say they wouldn’t be without one.
While unable to provide specific statistics, Ms Deuel said the use of OCT in her practice over eight years, “has had a huge impact on earlier detection, especially in neovascular AMD and earlier referral for injections to preserve eye sight and earlier detection of glaucoma, especially before structural damage is seen.”
“Like X-rays at the dentist, the pathology is more obvious, so there’s less guessing and earlier diagnosis of pathology, hence referrals for early disease and treatment for glaucoma and macular degeneration,” she said.
In Ms Deuel’s practice, there is a fee associated with OCT, which is mostly used on indication, and otherwise on older patients over 55, those with a family history of eye diseases, suspect optic nerves, reduced vision etc.
Ms Kidson, who recently upgraded from the Topcon 3DOCT she’d had for over ten years to a Topcon Triton, routinely dilates all patients over 50, along with patients who have diabetes, glaucoma, macular degeneration, cataracts, etc.
“There are definitely things that can only be seen with OCT scanning. In-practice AMD monitoring, glaucoma suspect monitoring or Glaucoma treatment cannot be performed comprehensively without the relevant OCT scans,” she said.
Having tried various models to recoup the cost of investing in OCT, Ms Kidson stopped bulk billing (except under certain circumstances) and charges an eye screening fee inclusive of OCT. However, she said the cost of acquiring an OCT, “pales in significance when measured against the increased confidence gained when you are clinically backed by the latest technology that offers a wide variety of imaging options and amazing software for analysis.”
Additionally she noted that patients appreciate the quality of care provided. “Patients have a much better understanding of what is happening to their eyes and why referral or specific monitoring intervals are important. Adherence is now much higher… their appreciation translates into an understanding of your worth and the fees charged.”
Associate Professor Simon Skalicky, a glaucoma specialist and former President of Glaucoma Australia, is supportive of optometrists installing OCT in practice. “For most eye disease, early detection is important because we can’t undo previous damage. OCT leads to early detection and as a result of more optometrists using this technology, we are now seeing younger patients coming into the practice for the first time with signs of glaucoma.”
While “it would be good for all optometry practices to have OCT” he said it is not essential, and there can be a risk of generating false positive screenings and even over treating.
“There are other ways to detect glaucoma today, like monitoring eye pressure and visual fields, and in the future we will have access to genetic profile screening which will help determine those patients at risk who should be screened more often than others,” he said.
DATA CORROBORATES WITH PBS
Specsavers examines approximately 3.8 million patients in Australia each year, and collects data on each sight test, enabling the organisation to gain a clear picture of eye health across the nation – and to measure shifts in outcomes with the introduction of new processes and technologies such as OCT.
Mr Larsen said the increased detection of glaucoma by Specsavers optometrists is corroborated by PBS data that shows a dramatic rise in scripts for glaucoma management medications.
“PBS data tells us that since 2016 there has been an incremental increase of 40,000–50,000 glaucoma patients who have been identified, referred on to ophthalmology and are being treated for glaucoma,” he said. The scale of the impact is significant, most likely making Australia the first region globally that is impacting the 50% undiagnosed statistic.
“Many practices don’t understand the benefit of collecting data on every eye examination; they believe Specsavers does it for commercial purposes. However, it’s important because as we’re seeing, big data analysis is providing evidence to support investment in new processes and technologies to improve eye health outcomes.
“We have now validated Specsavers’ approach to introduce OCT and implement a clear standardised examination process – optometrists across the group are now detecting a far higher number of glaucoma and AMD suspects than ever before, and equally importantly, the false positive referrals are much lower than some sectors initially anticipated. That’s because in every circumstance, optometrists get a 3D map of the patient’s macula, so they’re in a far better position to detect early stages of disease, whether that’s the presence of fluid or drusen in macular degeneration or retinal ganglion cell loss in glaucoma,” Mr Larsen said. “We are also fortunate to work in an environment where ophthalmology works closely with optometry, resulting in regular individual feedback on clinical decisions.
“I challenge any optometrist to offer OCT to every patient for a month, and at the end of that month, to analyse the findings and consider whether or not to stop offering the same service. They won’t.”