Sheila Urquhart and Keshma Rughani explain the Peterborough glaucoma pathway, a scheme that is extended to a total of eight practices this month
The Peterborough glaucoma pilot was awarded in May 2004, and the scheme was started in January 2005. The scheme consists of three phases, all following the same basic pattern. In the initial phase, which is currently running, the referrals come from the hospital, consisting of new referrals and existing glaucoma patients, all deemed to be suitable by the ophthalmologists running the scheme (Figure 1).
These referrals are directed to one of the four community specialist optometrists (SOs). Upon request, a copy of the relevant notes is then sent to the optometrist by the glaucoma screening co-ordinator, who is based in the eye clinic. This enables an understanding of the nature of the referral, along with relevant ocular and medical history.
On examining the patient, a series of standard questions are asked, including presenting symptoms, previous eye problems, and hypertension and asthma medication. Risk factors are accounted for, such as family history, vascular problems, myopia, shallow angles, etc. As per the protocol and exclusion criteria, visual acuity, any RAPD and anterior chamber depth are recorded. The cornea and iris are examined, and intraocular pressure measured by Goldmann tonometry. A visual field test is performed. To standardise results, the same machine and programme are used by the hospital and all specialist optometrists, ie Humphrey 7-series visual field analyser. The patient is then dilated, unless shallow angles prohibit, and an assessment of the lens and optic nerve head is carried out. Finally, a digital photograph of the optic disc and retina is taken. Based on this information, the specialist optometrist has to make a diagnosis and suggest treatment.
All this information is then sent to the hospital, where two consultant ophthalmologists review the results and decide on the course of action. If there appears to be no risk of glaucoma, the patient is discharged to their own optometrist, otherwise the patient will be reviewed by the specialist optometrist at regular intervals. If the patient appears to have glaucoma, they will be asked to start glaucoma medication and will subsequently be reviewed by the specialist optometrist. If it cannot be decided whether the patient has glaucoma, they will be seen by the consultant within the local eye department.
In the second phase of the scheme, the referrals will come from the hospital, directly from the GP or from non-accredited optometrists. At this stage the specialist optometrists are fully accredited, and will only contact the ophthalmologists for advice or to refer unstable patients. It is hoped that treatment will be via a patient group directive (Figure 2).
In the final phase of the scheme, it is hoped that as well as the referrals from the existing sources, patients from 'at risk' groups will be seen on the scheme. These patients will be identified by the PCT. Hopefully, during this final phase; it will be possible to treat the patients using supplementary prescriber status (Figure 3).
As part of the extra training, interested optometrists had to attend a series of core lectures over three evenings, presented by local ophthalmologists, covering topics such as examination techniques, angle and optic nerve assessment, neurological and glaucoma visual fields, and medication. Protocol was discussed and the opportunity was given to make any modifications to the glaucoma screening assessment form that would be used by optometrists.
The second part of training involved practical sessions at the local eye department, either during the day or specially arranged evening clinics.
The first of these was a revision session on contact applanation tonometry and visual field testing. The following two involved examining patients under consultant supervision, and the final a discussion of case studies. Five optometrists completed the initial training, another seven are just coming to the end of their training. By the end of June 2005, this means that the scheme will be extended to a further five practices, bringing the total to eight. This will provide good coverage of the whole Greater Peterborough area.
To date, 114 patients have been seen through this new screening project, and the feedback has been positive, both from the patients and the ophthalmologists. At present the specialist optometrists are in different locations around Peterborough, giving the patients a choice of venue.
Appointments are available at a time to suit the patient - both evenings and weekends if required. Parking is considerably easier, and often the wait is not as long as at the hospital.
The patients feel more relaxed in the more familiar surroundings of an optometric practice, and there is more time to ask questions and raise any concerns they might have. The consultant ophthalmologist is always at the end of the phone should any patients prove to be a challenge.
With the projected increase in glaucoma in an ageing population, of 30 per cent by 2021, there is a very real need to reappraise or change the current system as it stands. Currently, up to 25 per cent of all eye appointments are glaucoma-related, this then gives a large and increasing number of follow-up appointments, which in turn leads to an increasing wait for new appointments, and overload in the eye clinics.
As the creation of a patient-led NHS gathers momentum and with the move towards patient choice, the utilisation of the local, interested optometrists makes excellent sense.
In Peterborough, a close working relationship has developed between the ophthalmologists, and the optometrists since 1998. This is when the diabetic shared-care scheme was first started; the direct cataract referral scheme was introduced in 2000 as a progression from the success of the diabetic screening programme. The next logical step was then the introduction of a glaucoma shared-care scheme. There was some talk of this even prior to the awarding of the National Eyecare Pilot. Since the awarding of this programme, the associated funding has made this step much easier to take.
From the optometrist's point of view, the scheme has increased the scope of daily practice. Clinical skills have become enhanced, such as optic disc assessment, analysis of visual field plots, Goldmann tonometry and anterior chamber angle assessment. In time it is hoped that the skills can be increased further to include gonioscopy and corneal pachymetry. Due to the nature of the training programme, there has been the development of a closer working relationship with the ophthalmologists in the eye department. The ophthalmologists have also been impressed with the high standard achieved by the specialist optometrists.
The existing shared-care schemes of diabetes and cataract have been very well received with the population of Peterborough, and from the early feedback, it seems that the glaucoma scheme will closely follow.
Acknowledgements:
The Collaborative Group at Peterborough District Hospital, especially: Sarah Westwood, project manager, and Susana Ramirez-Florez, consultant ophthalmologist and academic lead for the project.
Keshma Rughani is a specialist optometrist in glaucoma, practising at Specsavers, Peterborough. Sheila Urquhart is an optometrist practising at Specsavers, Peterborough, and is also a member of the PEC of Greater Peterborough Primary Care Partnership