View from the consulting room
Nigel Kirkpatrick is concerned about glaucoma and how we are coping with it nationally
Author: Nigel Kirkpatrick
This series of articles follows a talk I gave at 100% Optical in early 2022 and it would not be complete without a discussion of glaucoma.
I will approach this problem from two perspectives. One way is to look from the patient’s viewpoint and focus on managing their concerns about glaucoma. From the other end of the telescope, one can look at the bigger picture in terms of epidemiology and provision of care.
Glaucoma, to many patients, is a disease that tends to instil fear of imminent sight loss. The word itself suggests a serious disease, such as melanoma, carcinoma or lymphoma, where the suffix ‘-oma’ indicates a swelling or growth, but we, as professionals, know that glaucoma is nothing of the sort. Essentially it is an optic neuropathy that has an association with abnormal intraocular pressure. It is insidious and it is well known that the symptoms of glaucoma present at a late stage, by which time treatment can only slow progress rather than reverse it.
I receive many referrals to my clinic where patients are quite worried about a glaucoma diagnosis. This usually stems from a routine eye test that identified some feature that caused concern – a pressure rise, a cupped disc or an abnormal visual field.
Our clinical approach is to repeat the tests and take a view on the likelihood of the diagnosis. In many cases, patients are suspended in a watchful-waiting limbo where we do little but continue to observe for signs of possible glaucoma progression. I often tell patients that they are ‘glaucoma suspects’, but now, the diagnosis is not yet established. This is usually greeted with a sigh of relief. They then willingly return for regular review with the knowledge that early detection is the key to living a long life without the spectre of severe vision loss.
You might ask why don’t all optometrists do of this? Well, I think we are moving to a welcome place where optometrists are increasing their glaucoma skills and knowledge. This should allow them to perform the routine monitoring tests required and, if data is fed into a suitable electronic system, the results can be assessed by more than one skilled professional to determine the likelihood of progression. Talk of artificial intelligence in glaucoma data interpretation is persuasive but this may still take some time. I am mindful of the marked variation in interpretations that glaucoma consultants display when presented with the same information. This suggests there is still quite a bit of art at play, mixed with understanding the science of this disease.
Taking the big picture view, we see that the UK has a significant problem with glaucoma care provision. From studies, we suspect that about 2-3% of all over 50-year-olds have glaucoma, but a substantial fraction of these remain undiagnosed. This group often attend for eye tests, hence there is a steady stream of referrals of potential glaucoma cases to secondary care for diagnosis opinions, even where there are referral refinement schemes that help to reduce false positives. The diagnosis can be nuanced and take many visits to establish, leading to a significant demand for routine follow up.
Sadly, this is where the system is collapsing. There is a huge backlog of these patients in secondary care services. They are the Cinderellas of the medical world and have been forgotten about since there are no ‘targets’ for their review. Published data on the harm caused by delay is concerning and yet no progress has been made in this area for years.
Many NHS units keep a note of the backlog numbers and these are large, measured in the thousands or tens of thousands. Anecdotally, it has been suggested the number of NHS ophthalmology patients overdue a follow-up has reached 2 million and this will include some desperate cases, where vision loss is happening in a system that overlooks them.
Without urgent action, I fear that our worried patients and the lack of clinic capacity are on a collision course with us running into a dark corner with no visible means of escape. I think we will eventually need to develop a high-volume service for patients where reviews happen in a dedicated clinic, closer to home, using trained technicians applying high-tech apparatus to allow for timely monitoring. Remotely reviewed data will allow decisions to be made on the likelihood of disease progression, perhaps even with the alternative reality of artificial intelligence. This system already exists in some areas, but there is no national drive to champion it on behalf of our patients.
The big question is how long do we wait until the pips squeak? My preference is to act soon and to campaign for a national debate. The alternative cannot be contemplated.
- Nigel Kirkpatrick is a consultant ophthalmologist and medical director at Newmedica.