Statement on Glaucoma
December 2009
COLLEGE STATEMENT ON NICE GUIDELINES ON GLAUCOMA
The National Institute for Health and Clinical Excellence (NICE) published guidelines on the diagnosis and treatment of chronic open angle glaucoma and ocular hypertension in April 2009. Shortly following publication of the guidelines, the Association of Optometrists recommended that optometrists should refer all patients with intraocular pressure measurements over 21mmHg. As a result, many hospital eye departments have experienced a considerable increase in the number of patients referred with suspected glaucoma, many of whom after further investigation were found to have neither glaucoma nor ocular hypertension.
The Royal College of Ophthalmologists, the College of Optometrists and the Association of Optometrists agreed to convene a joint working party to develop supplementary guidance on the referral of patients with apparently elevated intraocular pressure, covering a number of areas which had not been included in the terms of reference for the NICE guidelines. The Royal College of Ophthalmologists was represented by Professor Stephen Vernon, Mr Ted Garway-Heath and Dr Alan Rotchford.
The output
of the working party "
Guidance on the referral of glaucoma suspects by
community optometrists" has been endorsed by the Council of the Royal
College of Ophthalmologists, the College of Optometrists, the
Association of Optometrists and the General Optical Council. It is concordant with the recommendations of
the NICE guideline on glaucoma, and it sets out recommendations for good
practice in the initial assessment of patients with suspected glaucoma in
community optometric practice. It also
makes recommendations to minimize the likelihood of over-investigation of
specific categories of individuals whose risk of glaucomatous optic nerve
damage is low.
Although the College recognizes that the pattern of referrals for suspected glaucoma is unlikely to return to that seen before April 2009, it welcomes the guidance and believes that it will help to reduce unnecessary referrals into the hospital eye service.
The
Chairman of the Professional Standards Committee
December 2009
October 2009
NICE guidance for glaucoma and ocular hypertension published in April 2009 advised on standards for diagnosis and management. The guidance has a three year implementation period. Referral criteria from the community and screening were not within the scope of the guidance. Advice from the Association of Optometrists on the day of publication of the guidance to their members was to refer all patients with an IOP over 21mmHg, regardless of the technique used for measurement, for a full assessment. This has led to an increase in the number of referrals to hospital eye departments of people who do not have either glaucoma or ocular hypertension. As a consequence false positive referrals are taking up limited resources and adversely affecting the care that can be offered to people with established eye disease.
The College of Optometrists advises their members that where glaucoma or ocular hypertension is suspected, IOP measurement should be repeated, preferably by applanation tonometry, a visual field test should be done and an assessment of the optic disc made.
Optometrists hold contracts with a Primary Care Trust. Where clinical referrals from optometrists do not provide adequate clinical information it would be reasonable for the Primary Care Trust to ask that these are provided before a hospital appointment is offered. Where colleagues are having problems with an increase in false positive referrals with inadequate clinical information we recommend you ask your Trust to contact your Primary Care Trusts and agree referrals be returned for that information to be provided before offering an appointment.
June 2009
Two important items of national guidance concerning services for the diagnosis and treatment of patients with glaucoma and ocular hypertension have been issued during 2009. In April, the National Institute for Health and Clinical Excellence (NICE) published guidelines on the diagnosis and treatment of ocular hypertension and open angle glaucoma after a period of consultation (http://www.nice.org.uk/Guidance/CG85). In June, the National Patient Safety Agency (NPSA) issued a rapid response report (RRR) to healthcare organisations in England following a number of reports of avoidable visual loss in patients with established glaucoma due to delays or cancellation of follow up appointments (http://www.npsa.nhs.uk/nrls/alerts-and-directives/rapidrr/glaucoma/). The RRR requires healthcare organisations to audit hospital-initiated cancellation of appointments for patients with glaucoma or suspected glaucoma and to ensure that there is sufficient capacity to monitor these patients at appropriate intervals.
The NICE glaucoma guidelines and the RRR place a responsibility on ophthalmologists and healthcare organisations to work together to even up the standards of care for glaucoma sufferers. In addition to the safety incidents which triggered the RRR, there is considerable anecdotal evidence that pressure to reduce waiting times for first appointments, pressure to improve new to follow up ratios and staff shortages are particularly likely to have a detrimental impact on the timeliness of follow up appointments for patients with glaucoma.
The College acknowledges that implementation of the NICE glaucoma guidelines and the NPSA's RRR will place additional demands on hospital eye departments and on the health economy as a whole, at least in the short term. However, their implementation is entirely concordant with the principles set out in Lord Darzi's report: "High quality healthcare for all"
The situation has been complicated by varying interpretations of the NICE glaucoma guidelines. The Association of Optometrists issued a statement advising members that any intraocular pressure reading over 21mm requires a referral to the hospital eye service. NICE subsequently issued a statement of clarification (http://www.nice.org.uk/guidance/index.jsp?action=article&o=44291) indicating that the diagnosis of ocular hypertension requires that the intraocular pressure is consistently or recurrently greater than 21mm when measured with Goldmann applanation tonometry. The statement also emphasises that full implementation of the guideline is likely to take three years.
The College has received reports that, despite NICE's statement of clarification, there has been a sharp increase in referrals of patients with suspected glaucoma or ocular hypertension to hospital eye departments, many of which directly cite the advice issued by the Association of Optometrists.
The College is seeking early clarification of the situation with relevant stakeholders, but in the meantime, hospital eye departments may be obliged to seek additional funding from primary care trusts to cope with the rapid increase in demand. Members should consider encouraging their trusts or Health Boards to recruit additional ophthalmologists with an interest in glaucoma to provide additional capacity to meet the requirements of the NICE guidelines and the RRR.
A number of hospital eye departments have already implemented innovative and efficient clinics where ophthalmologists supervise technicians or optometrists who have been trained to undertake the initial assessment to distinguish normals from ocular hypertension and true glaucoma suspects in accordance with the NICE guidelines. Eye departments should consider this as an option for managing a rapid increase in referrals. It should be possible to expand existing hospital-based schemes or establish new ones relatively quickly, though this will place additional short-term training demands on consultant ophthalmologists.
Some areas have existing referral refinement programmes involving community optometrists and it may be possible to increase their capacity in the medium term. If current levels of referrals persist, it may be possible to establish further community-based referral refinement schemes in some areas as a medium to long term strategy although the organisational and training requirements for setting up such schemes should not be underestimated.
Richard
Smith
Chairman
of Professional Standards Committee
June
2009