Glaucoma referral and dischargeGlaucoma referral and discharge

SIGN guidelinesSIGN guidelines

Roshini Sanders Roshini Sanders Consultant ophthalmologist, DunfermlineConsultant ophthalmologist, DunfermlineConsultant ophthalmologist, DunfermlineConsultant ophthalmologist, Dunfermline

(On behalf of the SIGN group)(On behalf of the SIGN group)

NES, Glasgow, October 2014NES, Glasgow, October 2014

The need for a guidelineThe need for a guideline

�� NICENICE

�� European Glaucoma Society guidelinesEuropean Glaucoma Society guidelines

�� Plethora of regional guidelinesPlethora of regional guidelines

�� RReferraleferral and not diagnostic guidelineand not diagnostic guideline

�� Safe discharge into community with treated diseaseSafe discharge into community with treated disease

�� Community monitoring of high risk groupsCommunity monitoring of high risk groups

�� Scottish GOS/totally devolved from UKScottish GOS/totally devolved from UK

NICE NICE –– not so nice for Scotlandnot so nice for Scotland

�� Diagnostic guideline based on IOP of 21Diagnostic guideline based on IOP of 21

�� IOP of 21 based on Welsh study in 1970’s with 16.5 IOP of 21 based on Welsh study in 1970’s with 16.5 average IOP and over 21 > 2SDaverage IOP and over 21 > 2SD

Did not take into account Scottish GOS and Did not take into account Scottish GOS and �� Did not take into account Scottish GOS and Did not take into account Scottish GOS and optometry expertiseoptometry expertise

�� Flooded English OPDsFlooded English OPDs

�� Further NICE revised guidanceFurther NICE revised guidance

Current Glaucoma ChallengesCurrent Glaucoma Challenges

�� Ageing population with increasing glaucomaAgeing population with increasing glaucoma

�� False positive and false negative referralsFalse positive and false negative referrals

�� Patient educationPatient education

Hospital pressuresHospital pressures�� Hospital pressuresHospital pressures

�� Inadequate feedback and communication Inadequate feedback and communication

�� Increasing Increasing technology v patient centred caretechnology v patient centred care

Current Scottish glaucoma Current Scottish glaucoma service provisionservice provision

Optometrist led clinic, 8

Nurse led clinic, 2

Orthoptist led clinic, 1

Consultant led clinic

Optometrist led clinic

Nurse led clinic

Nurse led clinic, 12

Optometrist led clinic, 6

Orthoptist led clinic, 1

Consultant led clinic

Nurse led clinic

Optometrist led clinic

New Returns

Consultant led clinic, 89

Orthoptist led clinic

Consultant led clinic, 81

Optometrist led clinic

Orthoptist led clinic

60%

32%

8%

Simple discharge

Discharged to namedoptometrist

Discharged to a shared careteam

Discharge

Glaucoma EPR current referral dataGlaucoma EPR current referral data

� 2

DIAGNOSIS 2000-2006 2007-2012 P-Value

NORMAL 623 (37.6%) 380 (24.1%) < 0.0001*

GLAUCOMA

SUSPECT

425 (25.4%) 659 (41.9%) <0.0001*

OCULAR

HYPERTENSION

286 (17.3%) 242 (15.4%) 0.3732

HYPERTENSION

LOW TENSION

GLAUCOMA

16 (1%) 12 (0.7%) 0.5072

CHRONIC OPEN

ANGLE

GLAUCOMA

73 (4.4%) 113 (7.2%) 0.0350*

OTHER 105 (6.3%) 164 (10.5%) 0.0034*

MISSING DATA 132 (7.9%) 4 (0.2%) <0.0001*

National Ophthalmic PressuresNational Ophthalmic Pressures

�� ↑↑ New time sensitive treatments New time sensitive treatments

�� ↑↑ Referrals & Ageing population Referrals & Ageing population

�� ↑ ↑ Guidelines & TargetsGuidelines & Targets

�� ↓ ↓ Ophthalmic Work ForceOphthalmic Work Force

�� ↓ ↓ Resource Time & FinanceResource Time & Finance

�� ↓ ↓ Capacity & SpaceCapacity & Space

Press AlertsPress Alerts

�� Nine patients loose Snellen’s Visual acuity as a Nine patients loose Snellen’s Visual acuity as a consequence on managers moving glaucoma follow consequence on managers moving glaucoma follow up appointments to accommodate new patient slotsup appointments to accommodate new patient slots

(NICE alert 2009)(NICE alert 2009)(NICE alert 2009)(NICE alert 2009)

�� Optometrists having a scattergun approach to Optometrists having a scattergun approach to screening tests that have little value and possibly screening tests that have little value and possibly increase false positive referralsincrease false positive referrals

(BMJ 2014)(BMJ 2014)

Advanced Glaucoma Advanced Glaucoma –– Optometry endOptometry end

Patient Factors Patient Factors –– three months three months apart apart –– hospital endhospital end

False positive v Clinical RiskFalse positive v Clinical Risk

SIGN SIGN -- methodologymethodology

�� Recommendations Recommendations –– systematic reviewssystematic reviews

-- randomised controlled trialsrandomised controlled trials

-- MetaMeta--analysesanalyses-- MetaMeta--analysesanalyses

�� Good practice points Good practice points –– SIGN expert opinionSIGN expert opinion

-- Practical applicability to regionPractical applicability to region

First ophthalmology guidelineFirst ophthalmology guideline

SIGN SIGN –– group and processgroup and process

�� All stake holder participation (18)All stake holder participation (18)

�� Eighteen monthsEighteen months

�� Open meetingOpen meeting

Peer review (20)Peer review (20)�� Peer review (20)Peer review (20)

�� Editorial reviewEditorial review

�� Final version (early 2015)Final version (early 2015)

SIGN SIGN -- overviewoverview

�� Awareness of risk factorsAwareness of risk factors

�� Referral guidanceReferral guidance

�� Safe discharge from hospital to communitySafe discharge from hospital to community�� Safe discharge from hospital to communitySafe discharge from hospital to community

�� Monitoring of high risk groupsMonitoring of high risk groups

�� Patient versionPatient version

General assessment of patients General assessment of patients risk factorsrisk factors

�� Age, sex, race, FHAge, sex, race, FH

�� RRefractive error, PXF, Pig Disp, Angle closureefractive error, PXF, Pig Disp, Angle closure

�� General health General health –– Diabetes, Hypertension,Diabetes, Hypertension,

Peripheral Vascular DiseasePeripheral Vascular DiseasePeripheral Vascular DiseasePeripheral Vascular Disease

�� IOP IOP –– OHT/EGPS risk modelOHT/EGPS risk model

-- Age , IOP, CCT, Vertical C/D ratioAge , IOP, CCT, Vertical C/D ratio

-- Risk calculator/NICERisk calculator/NICE

Primary Examination Primary Examination -- OHT/glaucoma suspectsOHT/glaucoma suspects

�� IOP readings x 2IOP readings x 2

�� CCTCCT

Van HerickVan Herick�� Van HerickVan Herick

�� Optic disc assessment, Disc photographyOptic disc assessment, Disc photography

�� Automated perimetry x 2Automated perimetry x 2

Referral to Hospital Referral to Hospital

�� IOP > 25, irrespective of CCT (maybe clause)IOP > 25, irrespective of CCT (maybe clause)

�� IOP 22IOP 22-- 25, CCT < 555, aged <6625, CCT < 555, aged <66

�� Community monitoring Community monitoring –– all othersall others

i.e.i.e.

�� IOP < 26 and CCT >554 IOP < 26 and CCT >554

What does this mean?What does this mean?

�� 21 mmHg no longer threshold21 mmHg no longer threshold

�� Need CCTNeed CCT�� Need CCTNeed CCT

�� Take age into considerationTake age into consideration

�� More comprehensive assessment of risk factorsMore comprehensive assessment of risk factors

�� Robust documented method of annual recallRobust documented method of annual recall

Referral outReferral out

�� IOP < 26, CCT >554, untreatedIOP < 26, CCT >554, untreated

�� IOP > 25, low lifetime risk, untreatedIOP > 25, low lifetime risk, untreated

�� Treated OHT, normal examination, low riskTreated OHT, normal examination, low risk�� Treated OHT, normal examination, low riskTreated OHT, normal examination, low risk

�� Treated stable glaucomaTreated stable glaucoma

�� Post iridotomyPost iridotomy

What What does this mean?does this mean?

�� MMuch closer communication between hospital and uch closer communication between hospital and communitycommunity

�� Patient informed consentPatient informed consent�� Patient informed consentPatient informed consent

�� Knowledge about glaucoma treatmentsKnowledge about glaucoma treatments

�� Additional qualificationsAdditional qualifications

�� Robust documented method of annual recallRobust documented method of annual recall

Monitoring at risk groupsMonitoring at risk groups

�� OHT OHT –– every two years (R)every two years (R)

�� Myopia, tilted disc, optic drusenMyopia, tilted disc, optic drusen

�� PXF, Pig DispPXF, Pig Disp

�� Post iridotomyPost iridotomy

PXF PXF –– To see or not to see ?To see or not to see ?

Disc dilemmasDisc dilemmas

Normal or Abnormal?

Tilted, peripapillary atrophy Normal

Scottish Service ProvisionScottish Service Provision

�� General ophthalmic services arrangementsGeneral ophthalmic services arrangements

�� Eyecare Integration ProjectEyecare Integration Project

�� Sci GatewaySci Gateway

�� Improved four way communicationImproved four way communication�� Improved four way communicationImproved four way communication

�� Patient centred servicePatient centred service

�� Delivery of timeous treatmentDelivery of timeous treatment

�� Identification of suitable community careIdentification of suitable community care

SIGN recommendationsSIGN recommendations--shifting shifting the goal poststhe goal posts

�� Acknowledging high standards of Scottish Acknowledging high standards of Scottish optometryoptometry

�� Ability to truly diagnose OHTAbility to truly diagnose OHT

�� Acknowledging need for good communication and Acknowledging need for good communication and �� Acknowledging need for good communication and Acknowledging need for good communication and patient centred carepatient centred care

�� DDLSDDLS

�� Corneal pachymetryCorneal pachymetry

�� Van Herrick v GonioscopyVan Herrick v Gonioscopy

�� TrainingTraining

Disc Damage Likelihood scale (DDLS)Disc Damage Likelihood scale (DDLS)

DDS DDS -- Healthy small discHealthy small disc

National IT Equipment SurveyNational IT Equipment Survey

89%

15%

Contact Tonometer

Pachymeter

98.50%

100%

89%

Digital Camera

VFA

Contact Tonometer

Implications Implications –– HospitalsHospitals

�� Establishing routine good feedback and Establishing routine good feedback and communicationcommunication

�� Involving patient in decisions concerning follow up Involving patient in decisions concerning follow up arrangementsarrangementsarrangementsarrangements

�� Hospital RegisterHospital Register

�� Medico Medico ––legal responsibilitieslegal responsibilities

Better worldBetter world

COeRU Optometry Referral Form

PATIENT DETAILS

Title: Mrs Surname: First Name(s)

Address:

Address: Postcode

Tel: Mobile: Date of Birth 1937

Date of Exam 15/01/13 PRIORITY (Routine / Soon / Urgent) Routine

REFRACTION DETAILS

Vision Sph Cyl Axis Prism Base VA Add Near VA

R +1.00 +0.75 180 6/6 +2.50 N5

L +1.25 +1.00 170 6/6-2 +2.50 N5

Seen at Eye Clinic Previously? Yes Does Patient wish Clinic Appointment? CHI No Does Patient wish cataract surgery? Date Seen at Eye Clinic Does Patient require further advice

Primary patient complaint

Routine check. Primary / Provisional Diagnosis: Unsure, possible low tension glaucoma.

Secondary Diagnosis / Other Conditions:

Additional Information / Clinical Findings: Mrs intitially attended us on 6th December 2012 for a routine eye examination. On visual field screening a relative scotoma was plotted on the upper nasal right field. Previously field screening were clear. Mrs returned for threshold field test and the field defect was confirmed. C/D right 0.6/0.7 vertical appears narrowed rim at 7 o'clock. C/D left C/D 0.4 (superior cupping). On slit lamp the angles appear open.

Intra-Ocular Pressures

Perkins

R (mmHg)

14 RECOMMENDED INFORMATION

GLAUCOMA Disc Assessment Contact TonometryVisual Fields CATARACT Dilated retina assessmentMACULAR DISEASE

Near Visual AcuityMacular appearance

Note to General Practitioners: Please could you forward relevant clinical information to the COERU as soon as possible. You may do this using either SCI Gateway or NHS Mail to fife-uhb.qmh-eye-clinic@nhs.net It may also be forwarded using traditional methods although appointments will be provided to patients within 48 hours of receipt of this referral.

Attached Files General Practitioner Referring Optometrist Fields (Humphery) and retinal images right and left.

Diagnosis at 1st clinic visit

LTG1%

OHT17%

Not recorded

2%

CCAG1%

Other5%

Glaucoma AuditGlaucoma Audit

COAG7%

Glauc. Susp.22%

Normal45%

Patients with clinic IOP>=30(n = 32)

40

50

60

70IO

P

Glaucoma AuditGlaucoma Audit

0

10

20

30

0 100 200 300

No. of days

IOP

Thank you Thank you