High street optometry continues to play an increasing role in the management of chronic open angle glaucoma, which accounts for 90% of patient cases, and stricter thresholds for referral could place even more power in its hands.
New guidelines by NICE also include a section on the tests that should be carried out by primary eye care professionals to determine if referral to a specialist is necessary.
Those providing enhanced glaucoma services now have a solid NICE framework to use as a reference. The guidelines add to frameworks by the Local Optical Committee Support Unit (Locsu) and guidance from optical bodies including the College of Optometrists.
However, while hundreds of local optical committees across the country have managed to secure glaucoma repeat readings and OHT monitoring pathways, frustration remains over the lack of a national contract (Visus 17.11.17). Thus, the suggestion that NICE’s increased thresholds acted to reduce false positives was deemed ‘fictitious’ given the patchy commissioning picture.
Moreover, more rigid referral guidelines could even steer CCGs away from contracted glaucoma schemes, according to Locsu.
Richard Whittington (pictured), chief operating officer of Locsu, told Optician high street glaucoma services should ‘most certainly’ be commissioned on a national basis.
Locsu reported that 189 CCGs have live enhanced glaucoma services, including 144 glaucoma repeat readings schemes, 31 for glaucoma referral refinements and 14 for stable glaucoma monitoring.
However, Whittington warned the new NICE guidelines could result in fewer schemes being commissioned by CCGs.
‘One thing that could happen is that CCGs choose not to commission IOP schemes as the number of patients being referred will reduce due to the increased threshold. Commissioners may choose to wear the false positives, on the assumption that there will be fewer due to the raised thresholds, and save the money that is being spent on the community schemes. I do think that is a genuine risk,’ he added.
Justified change
New guidance by NICE (News 03.11.17) recommended a higher inner eye pressure threshold of 24mmHg to prompt referral and treatment, up from 21mmHg previously. Patients with an inner eye pressure below 24mmHg were to continue regular visits to their primary ECP for further detection.
It was estimated that approximately 1.8 million people in the UK had an inner eye pressure of 22 or 23mmHg.
Professor Mark Baker, director of the centre for guidelines at NICE, said: ‘Increasing the treatment threshold will not only lead to fewer patients being referred unnecessarily but it should reduce costs without compromising patient safety.’
Other recommendations by NICE included using gold standard equipment to measure a patient’s intraocular eye pressure and repeating tests before referral. This included using stereoscopic slit lamp biomicroscopy, OCT, Goldmann-type applanation tonometry and gonioscopy.
A briefing by the College of Optometrists following the NICE changes presented the key points for optometrists providing community services such as repeat measures or referral filtering schemes. It said the new guidelines made it clear that optical practitioners should not refer solely on IOP measurement using non-contact tonometry.
When elevated pressure of 24mmHg or above was the only finding, a Goldmann-type pressure should be measured prior to any hospital eye service referral.
The College briefing also noted optometrists should not refer patients who have been discharged from the hospital eye service after an assessment for glaucoma, ‘unless clinical circumstances have changed and a new referral is fully justified’.
Under only GOS, without a referral filtering service, patients should be referred upon the discovery of optic nerve head damage, a visual defect consistent with glaucoma, or when IOP is 24mmHg or above, the briefing confirmed.
Ending uncertainty
The Royal College of Ophthalmologists (RCO) told Optician the new guidelines addressed current uncertainty around pressure readings, which was resulting in unnecessary referrals.
Professor John Sparrow, clinical lead, National Ophthalmology Database Audit (NOD) at the RCO, said: ‘The higher threshold acknowledges the measurement uncertainty associated with small numbers of readings close to a threshold value as well as the uncertainty about the relationship between pressure and risk towards the low end of the pressure-risk relationship.
The guideline makes clear that pressure alone does not confirm or refute the diagnosis of glaucoma, but that a minimally raised pressure without any other signs of glaucoma can be safely managed without unnecessary hospital referrals.’
While the RCO did not believe the goal of reducing false positives was at the root of the revised guidance, it expected to see results.
Prof Sparrow added: ‘This was not the primary intention [of the NICE guidance], which is to ensure safe care of patients with suspected or actual glaucoma. However, because the guidelines help to ensure that people who are at real risk of glaucoma are detected and referred while people whose risk is negligible or non-existent are not exposed to needless anxiety and inconvenience of attending hospital only to be immediately discharged again, the natural consequence of the update to the clinical guidelines is that there are likely to be fewer false positives. This will help to deliver added efficiency to both high street optometrists and the hospital eye services which are under pressure.
‘High street optometric practices are not being asked to undertake extra monitoring outside of commissioned schemes. The guideline recommends people with normal optic nerve heads and fields whose pressure is 22 or 23mmHg are seen again by their optometrists in the usual way as they would normally be, for example, many optometric practices currently operate a two-year recall for their patients.
The principle is the same as now, but the threshold level of pressure concern has increased slightly from 21mmHg. Goldmann-type pressure measurement should already be available in the vast majority of practices.’
A welcome change
The new glaucoma guidelines were welcomed by the International Glaucoma Association, which said they provided clear referral criteria. Karen Osborn, chief executive of the International Glaucoma Association, said: ‘We believe the revised NICE glaucoma guideline is helpful and will help to reduce unnecessary referral to secondary care services. The evidence cited in the guidance stresses the importance of not basing a referral on IOP measurement alone, and emphasises the importance of other glaucoma tests such as visual field and optic nerve examination.
‘The increase in IOP threshold to 24mmHg will reduce the number of unnecessary referrals without risking not identifying people who are at significant risk to sight from glaucoma.
‘We know from the Royal College of Ophthalmologists and from callers to our helpline that hospital eye services are over-stretched. This guidance will have a positive impact on waiting times and appointments, helping to ensure that those most in need of specialist services receive timely diagnosis and treatment.
‘There are many different commissioning models around the country. We encourage all commissioners to refer to these guidelines to reduce local variations and ensure a minimum standard of care for people with ocular hypertension and suspect glaucoma.’
How helpful are the new NICE guidelines?
Adam Wannell (pictured), head of EOS at Specsavers, also welcomed the new guidelines, saying community optometrists were better prepared than ever to engage with glaucoma monitoring services.
He said: ‘Many practices have heavily invested in technology over the last few years and are now at least on par with hospital eye departments in terms of the standard of equipment available, with contact tonometry, threshold visual fields and digital imaging now commonplace.
‘Furthermore, the rollout of OCT in Specsavers stores is well under way and despite this technology not being a widespread part of the current glaucoma secondary care pathway, I believe it is only a matter of time before that is the case and follows through into community services. This combined with the large uptake of additional training and professional qualifications by optometrists from a range of providers such as Wopec, means UK optometry has the impetus to become more widely involved in monitoring services.
‘Specsavers would welcome any additional community involvement in glaucoma services. Indeed, this was in part a reason why Specsavers embarked on the training of unprecedented numbers of optometrists to achieve level 1 and 2 glaucoma accreditations, which has now stands at 1,850 of our practitioners in addition to the thousands of accreditations for Mecs and cataract. This has also led many practitioners to develop a thirst for further training, resulting in increased uptake of College higher qualifications.’
Wannell also believed glaucoma services should be commissioned on a national basis.
He added: ‘The success of the Scottish and Welsh models have shown these services to be scalable to larger populations – and ultimately provide benefits for the patients and the system.’
Missing technology was deemed a barrier to the national approach, but Wannell said the digitalisation of referrals across the NHS presented an opportunity to become more integrated.
Prof Sparrow added: ‘The current system of fragmented and inconsistent commissioning, pathways and protocols means that patients are being provided with variable levels of care depending on where they live and makes establishing enhanced schemes difficult. It is possible that regional or national commissioning can address this but it would be very important to ensure that high street optometrists are able to work closely with their relevant secondary care hospital colleagues in terms of clinical governance and ensuring patient safety, clinical communication, professional development and joined up care.’
Visit www.nice.org.uk/guidance/NG81 to read the new NICE glaucoma referral guidelines in full.