Glaucoma Referral Refinement: Glaucoma Referral Refinement: Bob Wilkes

Chairman

Central Mersey Local Optical Committee

Current Position

• All suspect glaucoma referred to secondary care due to constraints of GOS sight test

• Low prevalence: Only 4 in 10 referrals are • Low prevalence: Only 4 in 10 referrals are positive (Still 97% sensitivity)

• NICE Guidance: Lower IOP threshold

▫ Large increase in referrals

▫ Only addresses suspect IOP

Nice Guidance

• About diagnosis and treatment

• Not about referral

• Goldmann standard• Goldmann standard

• No fields standard!

Referral Refinement

• Repeating tests:

▫ Increases specificity and sensitivity

▫ Increase in true positives

• LOCSU 1a• LOCSU 1a

▫ Applanation Tonometry

▫ “Gold Standard”

• LOCSU 1b

▫ Repeat suspect fields

Applanation Tonometry (AT)

• Tends to read lower that NCT

• >70% Deflection rates

• Goldmann type• Goldmann type

▫ KAT acceptable

• Perkins allowed

Tonometry workshop

• Core competency

• No accreditation required

• Mentoring • Mentoring

• Get started

• Brush up rusty skills

• Practice on model patients

Visual Field Refinement

• Suspicious visual field at sight test• Repeat measurement on a separate occasion• Equivalent or higher level • Equivalent or higher level strategy▫ Defect confirmed: Refer▫ Improvement: Recall for further ST in 6 months

▫ No defect: Recall in 12 months

Visual Field assessment

• Computerised test

• Supra-threshold/Threshold

• Threshold for repeat• Threshold for repeat

• Potential topic for lecture

• Coupled with Optic nerve head assessment

• New technologies: OCT/HRT.

Referral exclusions

• Joint Colleges advice:

• Patients aged 80 years and over with measured IOPs < 26mmHgIOPs < 26mmHg

• Patients aged 65 and over with IOPs < 25mmHg

• Where there is no other suspicion of glaucoma

Some scenariosSome scenariosExperience from refinement in Halton & St Helens

Patient A

• Discs and fields suspect

• Glaucomatous signs

• Family History of • Family History of Glaucoma

• IOP: 25mmHg with NCT

• Refer to HES

Patient B

• Any age• Discs and fields normal• Angles normal (van Herrick)• IOP: 25mmHg with NCT• IOP: 25mmHg with NCT• Repeat with AT▫ IOP: 21mmHg

• Recall in 12 months

Patient C

• 62 years old• Discs and fields normal• Angles normal (van Herrick)• IOP: 25mmHg with NCT• IOP: 25mmHg with NCT• Repeat with AT▫ IOP: 23mmHg

• Refer to HES• If patient>65: don’t refer • If patient >80: only refer if

final IOP is >25mmHg

Patient D

• Suspect Discs

• IOP: 20mmHg

• Supra-Threshold Fields:• Supra-Threshold Fields:

▫ Possible defect

• 1 week later

▫ Threshold Fields: Normal

• Recall in 6 or 12 months

Patient E

• Suspicious Discs

• IOP: 23mmHg with NCT▫ 21mmHg on repeat with AT▫ 21mmHg on repeat with AT

▫ Supra-threshold Fields: Possible defect

• <2 weeks later▫ Threshold Fields: Defect

confirmed

• Refer to HES

Benefits for the Patient

• Choice

▫ Venue and time

• Convenience

▫ Care close to home▫ Care close to home

• Speed of access

▫ Early intervention

• Quality▫ Core competency

Benefits for GP Practice

• Simple referral process

• Local choice

• Fits ‘Choose and Book’• Fits ‘Choose and Book’

• Rapid access

• Reduction in GP consultations

• Retaining patients in primary care where appropriate

• Cost benefits

Summary

• Reduction of unnecessary HES appointments, reducing patient anxiety, and generating capacity in hospital clinicsgenerating capacity in hospital clinics

• Ensuring secondary care availability of follow up care for those with established disease

• Cost effective service with more patients managed within primary care

Some figures

Cases Not referred Fees HES

LOCSU 1a 12 11 £180 £2,189

Patients seen since October 2010

LOCSU 1b 11 8 £275 £2,189

23 19 £455 £4,378

Saving £3,923

Times 25 £98,075

Less FU £57,825

Estimate £75,000

Thanks you for listening

Glaucoma Referral Refinement: Glaucoma Referral Refinement: Bob Wilkes

Chairman

Central Mersey Local Optical Committee