Advice for Optometrists not currently registered on the Glaucoma Repeat Reading Service.

Following the recent publication of revised glaucoma guidelines by NICE, LOCSU have produced guidance for optometrists who are not currently accredited on the Cheshire glaucoma repeat reading service.

I have included the LOCSU guidance below and highlighted the appropriate changes. These changes relate mostly to the threshold IOP level being increased from 21 to 24mmHg. LOCSU advise that people with IOP below 24mmHg should be advised to continue with their routine sight tests and do not need referring on IOP alone. IOP’s of 24mmHg and above should be repeated with a contact method like Goldmann.

NICE also recommends that patients who are being referred with suspect COAG should be offered all of the following tests before referral: central visual field testing, optic nerve assessment and anterior chamber depth assessment (see below for more details)

The aim of these new guidelines is to reduce unnecessary hospital outpatient appointments which can add to already overcrowded glaucoma clinics, adding possible delays to glaucoma care for our patients.

The NICE guidelines also encourages the use of repeat reading services like the Cheshire Wide GRR service. Non-participating practices are encouraged to refer patients with IOP’s measuring 24mmHg or above or with field defects which may be glaucomatose but with no other signs of glaucoma to an accredited practice on the GRR service. I have included guidance on this referral pathway below, the practice list is available on the LOC website. If you offer your patient the choice of accredited practice and then refer directly to that chosen practice including as much detail as possible.

For practices wanting to join the Cheshire-wide Glaucoma repeat reading service, which allows for repeat Goldman IOP measurements and repeat field tests to be paid for, please see the Cheshire LOC website enhanced service page and contact your areas clinical lead. The repeat reading service has been working well for the past few years to help both optometric practices be financially remunerated for repeating measurements related to glaucoma referrals, and has also shown to reduce unnecessary out patient appointments.

Many Thanks

Amy Thompson

Cheshire LOC and East Cheshire PECC, GRR clinical Lead.

“Level 1c: Patients from non-participating practices

“In this case it should be emphasised that the second optometrist assumes clinical responsibility for the detection of the patient suffering from glaucoma or ocular hypertension. Therefore assessment of the optic disc, anterior angle and where appropriate, visual field is necessary.

These additional examinations required will take more time and thus a greater remuneration is provided.

In these cases non-participating practices should where possible ask the patient to select a participating practice and send the referral details directly to that practice as per local referral protocols. This will enable the patient to experience the most efficient process to receiving the care they need.

The criteria for inclusion of patients in level 1c  IOP > 24 mmHg as measured at the sight test following College guidance on technique where NCT is used (4 readings), and no other signs of glaucoma are present or visual field defect which may be due to glaucoma and requires further investigation, and no other signs of glaucoma are present.

NB: Glaucoma is a very slow developing disease and there is very little risk to the patient in delaying the repeat tests. The reason for repeating the tests on a different occasion is to ensure that factors that may have influenced the patient responses the first time round, particularly in the fields test, will be different. “

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NICE Glaucoma Guideline (NG81)

Appendix 3 Summary of NICE Glaucoma Guideline NG81 (LOCSU’s interpretation)

Referral

  • Patients should not be referred solely on IOP measurement using non-contact tonometry.
  • Where elevated pressure of 24 mmHg or above is the only finding (normal disc and field) then a Goldmann-type pressure should be measured prior to referral to the hospital eye service.
  • The accuracy of test results should be checked before referral for diagnosis of COAG or ocular hypertension (OHT) via repeat measures, enhanced case finding or referral refinement.
  • People with IOP below 24mmHg should be advised to continue with routine sight tests.
  • People who have been discharged from the Hospital Eye Service after an assessment for COAG and related conditions should not be re-referred unless clinical circumstances have changed.
  • If sight test findings show optic nerve head damage, a visual field defect consistent with glaucoma, or IOP 24 mmHg or above, the patient should be referred to the hospital eye service for diagnosis.
  • NICE recommends, before referral for further investigation and diagnosis of COAG and related conditions, people should be offered all the following tests:
  • central visual field assessment using standard automated perimetry (full or supra- threshold)
  • optic nerve assessment and fundus examination using stereoscopic slit lamp biomicroscopy (with pupil dilatation if necessary), and optical coherence tomography (OCT) or optic nerve head image if available
  • IOP measurement using Goldmann-type applanation tonometry
  • peripheral anterior chamber configuration and depth assessments using gonioscopy or, if not available or patient prefers, the van Herick test or OCT.

Optometristsworking in areas where no repeat measures scheme has been commissioned should not be criticised for an unnecessary high false positive referral rate which is the result of a failing of commissioning. However, if an optometrist chooses not to participate in a repeat measures service and an enhanced case finding or referral refinement service has been commissioned, non-participating optometrists should refer to an accredited optometrist of the patient’s choice, unless an emergency referral to the HES is indicated.

Organisation of care

People with suspected optic nerve damage or repeatable visual field defect, or both, should be referred to a consultant ophthalmologist for diagnosis and formulation of a management plan. Other clinicians with a specialist qualification relevant to the case complexity of glaucoma and relevant experience, can diagnose OHT and suspected COAG and formulate a management plan for these conditions.

Patient information

People attending glaucoma clinics should be offered the opportunity to discuss their diagnosis, referral, prognosis, treatment and discharge, and should be provided with relevant information in an accessible format.

Useful resources

Association of Optometrists member briefing

College of Optometrists member briefing

The LOCSU pathway and RCOpth Commissioning guidelines are currently being updated.