An audit on the impact of training for a Referral Refinement Scheme in Northern Ireland on community optometrists’ clinical practice when assessing for signs of glaucoma
AuthorsShelley Black*, Julie McClelland and Patrick Richardson
Optometry and Vision Science Research Group, School of Biomedical Sciences,
Ulster University, Coleraine, BT52 1SA, Northern Ireland, United Kingdom
AcknowledgementsThe authors wish to acknowledge the College of Optometrists for funding, Dr Sayeed
Haque for statistical support given to the project and the four community practices
and optometrists who participated in the audit.
Introduction Glaucoma services in Northern Ireland and other parts of the United Kingdom came
under significant pressure as the number of ocular hypertensive referrals to the
service increased in recent years (Shah et al. 2011; Ratnarajan et al. 2013). This
was a result of the implementation of NICE Clinical Guideline 85 (NICE 2009) in
2009 coupled with a recommendation from the Association of Optometrists that all
patients presenting with repeatable intraocular pressures (IOPs) of more than
21mmHg should be referred to an ophthalmologist regardless of the type of
tonometer used to make the measurement (AOP 2010).
Northern Ireland’s Health and Social Care Board engaged with the Belfast Local
Commissioning Group and other key stakeholders to commission a redesign of
glaucoma services with the aim of refining glaucoma referrals and reducing the false
positive referrals which were flooding the hospital eye service (HES).
The first glaucoma Local Enhanced Service (LES) began in December 2013 as a
repeat measure scheme to reduce false positive ocular hypertension referrals. To
partake in the scheme, primary care optometrists required training and accreditation
from Ulster University. Optometrists were issued with a distance learning package
consisting of video lectures in
1 Contact tonometry
2 Slit lamp binocular indirect ophthalmoscopy
Black et al OiP Submission 2017 1
3 Optic disc analysis
4 Anterior chamber assessment
The training package reviewed the importance of these four areas when assessing
for clinical signs of glaucoma. A summary of the training has been detailed below.
High IOPs
Patient’s presenting with high IOP are more at risk of glaucoma , however it is should
be noted that about 40% of patients with glaucoma have IOP within the normal range
(Shah et al. 2011). It is important for optometrists investigate other clinical signs
before deciding whether to refer the patient as a glaucoma suspect or ocular
hypertensive. The College of Optometrists advise that it is good practice to follow up
equivocal results from non-contact tonometry (NCT) with contact applanation
tonometry (CT) (CoO 2017).
Glaucomatous disc features
Binocular indirect ophthalmoscopy is the recommended method to examine the optic
disc as it enables a more accurate, less variable estimation of the optic cup to disc
size than direct ophthalmoscopy. Direct ophthalmoscopy tends to underestimate cup
to disc ratio (Watkins et al. 2003).
Jonas et al performed a major review of ophthalmoscopic evaluation of the optic
nerve head (Jonas et al. 1999). In order to detect early glaucomatous optic disc
damage in ocular hypertensive eyes before visual field loss occurs, the authors
recommend that the following features of the optic disc are assessed:
Shape of the neuroretinal rim (NNR)
Optic cup size in relation to the size of the optic disc
Quality of the retinal nerve fiber layer (RNFL)
Presence of disc hemorrhages
Shape of the neuroretinal rim (NRR)
In normal eyes, classically the perceived thickness of the NRR has a characteristic
pattern, based on the vertically oval shape of the disc and the horizontally oval
shape of the cup. The NRR is normally broadest inferiorly, then superiorly, then
nasally with the temporal region the narrowest, which lead to the development of the
“ISNT rule” (Harizman et al. 2006; Jonas et al. 1999).
Black et al OiP Submission 2017 2
It is important in the detection of glaucomateous disc damage to observe the location
and extent of any NRR loss as this can be indicative of the stage of the disease
progression (Hammel et al. 2016). Figure 1 shows NRR loss progression in a
glaucomatous disc. These changes correlate with the progression and location of
visual field defects with early glaucoma (Jonas et al. 1999).
Figure 1
Optic cup size in relation to the size of the Optic Disc
In normal eyes the size of the optic disc and optic cup should correlate with each
other; the bigger the disc, the bigger the cup (Jonas et al. 1988). A small disc with a
large cup or asymmetry between the cup to disc ratio would be suggestive of
glaucoma, particularly if the configuration of the NRR does not agree with the ISNT
rule (Jonas et al. 1999).
Quality of the RNFL
Black et al OiP Submission 2017 3
Glaucomatous optic nerve atrophy is associated with optic nerve fibre loss,
decreasing the visibility of the RNFL either diffusely or with localised defects (Jonas
et al. 1999; Jonas et al. 1994; Kubena et al. 2011). The RNFL can be viewed
through a red- free filter in direct or indirect binocular ophthalmoscopy or through a
red-free filter in fundus photographs. A wedge-shaped RNFL inferior defect is shown
in Figure 2 (Thomas R, 2006).
Figure 2
Presence of Disc Hemorrhages
A hallmark of optic disc atrophy is flame-shape hemorrhages at the edge of the optic
disc. Disc hemorrhages are rarely observed in non-glaucomatous eyes (1%) (Healey
et al. 1998; Klein et al. 1992) so normally indicate the presence of optic disc damage
(Jonas et al. 1999). Disc hemorrhages are often associated with localised RNFL
defects (figure 2), NRR notches and visual field loss (Jonas et al. 1994)
Anterior Chamber Angle (ACA)
Black et al OiP Submission 2017 4
The closure or blockage of the anterior chamber angle can lead to acute angle
closure glaucoma (ACG). There are certain ocular characteristics which predispose
the eye to ACG (Congdon et al. 1996; Dabasia et al. 2013; Lowe 1970);
i. Shallow ACA depth
ii. Anterior lens positioning
iii. Thickening of the lens
iv. Small corneal diameter
Nolan et al. (2006) highlighted shallow ACA as the prime risk factor for developing
ACG.
Pigment dispersion syndrome and pseudoexfoliation syndrome can result in
secondary glaucoma as a result of the trabecular meshwork becoming blocked
reducing aqueous drainage, raising IOP and damaging the optic nerve.
In community optometric practice, few practitioners have access to a gonioscope or
have training in gonioscopy (Jamous et al 2014; Lockwood et al. 2010; Myint et al
2010) which is the gold-standard method of assessing the anterior chamber.
However, where gonioscopy is not possible, Van Herick test is an acceptable
alternative in grading the anterior chamber angle depth (Dabasia et al. 2015). An
angle measured by Van Herick technique to be grade 2 or less should be referred to
secondary services for further investigation (CoO 2016; HIS 2015).
LES AccreditationLES accreditation was granted once practitioners successfully completed a multiple
choice written examination and practical assessment of contact tonometry, optic disc
analysis using slit lamp binocular indirect ophthalmoscopy and measuring the
anterior chamber angle using Van Herick technique. In August 2014 more than 250
optometrists in Northern Ireland had received accreditation, this has now risen to
over 350.
Accredited optometrists were to use the new referral refinement scheme pathway
when a patient presented with IOPs over 21mmHg. This pathway has been
summarised in Figure 3.
Black et al OiP Submission 2017 5
Figure 3
Many Health Boards across the UK have also introduced glaucoma referral
refinement schemes (Devarajan et al. 2011; Keenan et al. 2015; Ratnarajan et al.
2015; Trikha et al. 2012). The majority of these schemes have been evaluated by
auditing the quality and outcomes of the referrals received by the HES (Devarajan et
al. 2011; Ratnarajan et al. 2015; Trikha et al. 2012). There is limited data in the
literature demonstrating the views of providers as part of scheme evaluation (Baker
et al. 2016). Moreover, none have examined the impact of the additional training on
the day-to-day clinical practice of accredited optometrists.
The purpose of this audit was to explore whether LES accreditation impacted on
optometrists practice habits when assessing for signs of glaucoma following referral
refinement training.
Methods
The audit comprised three stages; in stage one the author, a glaucoma accredited
optometrist, examined the patient records of optometrists before and after they
received LES training, in stage two audited optometrists were surveyed on how they
Black et al OiP Submission 2017 6
felt the training impacted their routine clinical practice and in stage three the survey
was extended to all LES accredited optometrists in Northern Ireland.
Ulster University’s ethics filter committee and NHS ethics committee categorised this
study as an audit.
Stage 1Data from electronic patient records were collected from four community optometry
practices in Northern Ireland. Patient records were reviewed from a period before the
LES training took place (January 2013 to February 2013) and compared to a period
after the LES training (July 2014 to August 2014).
The inclusion criteria for the audit were records from patients who were over 40
years old and had a first degree family history of glaucoma (FHG). Age matched
records of patients without a FHG were included as controls. Patient records where
individuals had a diagnosis of glaucoma were excluded.
Records were reviewed for information on: intraocular pressure (IOP), optic disc
(OD) description, examination techniques used in ocular assessment, visual fields
and referral.
N.B. If an optometrist recorded a technique or description in 95% or more of their
audited patient records this was noted as ‘always’, 50% to 94% was noted as
‘usually’, 5% to 49% was noted as ‘sometimes’ and 0% to 4% as ‘never’. This is to
aid comparison of stage 1 and stage 2’s results.
Stage 2 Each optometrist from the four community practices participating in the audit was
emailed a link to complete an online survey. The survey was designed to elicit
information on the clinician’s practice with regards to how they assessed patients for
signs of glaucoma before and after they had LES training.
The survey comprised of eight closed questions, six of which required a four-point
scale response ranging from ‘never’ to ‘always’ and a final free response question
(Figure 4).
Black et al OiP Submission 2017 7
Figure 4
Stage 3Ulster University possess a list of all the optometrists who received accreditation
through their LES training programme. The optometrists were emailed an invitation
to complete the survey online. The survey consisted of the same questions used in
stage 2 (Figure 2) but with the additional free response question, ‘If you do not
always use a contact tonometer to repeat IOP measurement since becoming
accredited, please comment why’.
Results
Stage 1- Record AnalysisThe database of 13,031 records produced 1,138 records which met the inclusion
criteria; 604 pre-LES training, 534 post-LES training. Data from 17 optometrists
working in the four practices were included in the audit.
Comparison of individual optometrist’s records pre and post LES training
Twelve of the seventeen optometrists had a minimum number of forty records, 20
with a FHG and 20 without a FHG, which could be analysed pre and post LES
training. The analysis focused on three main areas of practice:
Black et al OiP Submission 2017 8
1. The method chosen for ocular examination on patients with and without a
FHG
2. The optic disc assessment in patients with a FHG
3. The assessment of the anterior chamber angle (ACA) in patients with a FHG
Instances in which initial IOP was over 21mmHg and where the patient was referred
along the referral refinement pathway were too few per optometrist to analyse
effectively. There was no access to visual field plots in two of the practices involved
in the audit. This was due to a change in filing system from paper to an electronic
database that was ongoing during the data collection period.
The results from Stage 1 have been summarised in Table 1. Comparison of the
individual optometrist’s record set from both pre and post LES training, highlights the
following key findings post training:
More of the optometrists are using indirect ophthalmoscopy to examine to
ocular health.
The optometrists increasingly record the quality of the optic disc’s
neuroretinal rim (NRR) in patients with a FHG.
The ACA in patients with a FHG is assessed by more optometrists the pre
training.
Black et al OiP Submission 2017 9
Table 1
Areas of Practice
Before LES Training %
(n)
After LES Training %
(n)
N=12 Optometrists
Method of Ocular Examination
Direct ophthalmoscopy used in ≥ 50% of the optometrist’s record set. (“Always/Usually”)
33% (4) 8% (1)
Indirect ophthalmoscopy used in ≥ 50% of the optometrist’s record set. (“Always/Usually”)
42% (5) 75% (9)
Method of ocular examination not recorded in the optometrist’s record set.
25% (3) 17% (2)
Recorded optic disc description in patients with a FHG
NRR recorded in <50% of the optometrist’s record set.(“Sometimes/Never”)
42% (5) 25% (3)
NRR recorded in ≥ 50% of the optometrist’s record set.(“Usually/Always”)
50% (6) 58% (7)
Optic disc compared to the ISNT rule in ≥95% of the optometrist’s record set. (“Always”)
8% (1) 17% (2)
Recorded assessment of the ACA in patients with a FHG
No assessment of ACA in the optometrist’s record set. (“Never”) 100% (12) 67% (8)ACA recorded in 5-49% of the optometrist’s record set.(“Sometimes”)
0% (0) 17% (2)
ACA recorded in 50-94% of the optometrist’s record set. (“Usually”)
0% (0) 17% (2)
Comparison of all records pre and post LES training
All 1138 records from the larger data set were analysed for statistical differences
between optic disc description, assessment of the ACA and the method chosen by
the optometrist for ocular examination pre and post LES training, Table 2.
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Table 2
Before LES Training % (n)N=604 records
After LES Training % (n)N=534 records
Indirect ophthalmoscopy used for ocular examination
56% (340) 67% (357)
Description of the optic disc’s NRR recorded
48% (290) 46% (246)
Assessment made of the ACA
0.2% (1) 5.2% (28)
No significant difference was found between the method chosen by the optometrist
to examine ocular health or in their description of the optic disc following training.
Statistical differences, however, were found using independent sample T test
between the number of records containing details of an ACA assessment pre and
post training. More records had an assessment of the ACA documented post training
(p=0.000, t[565]= -5.183), this was true for both patients with a FHG (p=0.000,
t[310]=-4.181) and those without a FHG (p=0.003, t[250] =-3.049).
Intra- Ocular Pressures (IOPs)
1,136 (99.8%) of the 1,138 patient records audited (with and without a FHG) had an
initial IOP measurement recorded, 43 (4%) of those had initial IOPs greater than
21mmHg, 32 pre LES training and 11 post LES training. In the pre LES records
where the IOPs were found to be over 21 mmHg, 11 (34%) had a repeat measure
made with a non-contact tonometer (NCT) and in 21 cases there was no repeat
measure made. Post LES training, 4 (36%) records had no repeat measure taken, 2
(18%) had a repeat measure recorded with a NCT and 5 (46%) had IOPs repeated
with a contact tonometer (CT).
Stage 2- Survey of audited optometrists All of the audited optometrists (n=12) completed the online survey. Tables 3,4 and 5
summarise the responses returned by the participants from questions 1 to 8 on how
they feel the additional training has impacted on specific areas of their daily practice.
Since receiving accreditation:
Black et al OiP Submission 2017 11
More practitioners report using indirect ophthalmoscopy when examining the
optic disc.
The number of optometrists assessing the anterior chamber in patients with a
FHG has increased.
More practitioners now use a contact tonometer to repeat IOPs if found
initially to be >21mmHg.
Little change was reported in what the practitioners record in their description
of the optic disc
Table 3
Never% (n)
Sometimes% (n)
Usually% (n)
Always% (n)
Before receiving LES training, did you use a volk lens and slit lamp to examine the optic disc?
0% (0) 33% (4) 0% (0) 67% (8)
After receiving LES training, do you use a volk lens and slit lamp to examine the optic disc?
0% (0) 17% (2) 0% (0) 83% (10)
Before receiving LES training, did you assess the depth of the patient’s anterior chamber of there was a FHG?
25% (3) 67% (8) 8% (1) 0% (0)
After receiving LES training, do you assess the depth of a patient’s anterior chamber if there’s a FHG?
0% (0) 25% (3) 50% (6) 25% (3)
Table 4
CD ratio only
% (n)
CD ratio and NRR
% (n)
CD ratio and ISNT
% (n)
CD ratio, NRR, cup
depth, ISNT% (n)
Before receiving LES training, what did you regularly record when describing the optic disc?
8% (1) 75% (9) 8% (1) 8% (1)
After receiving LES Training, what do you regularly record when describing the optic disc?
0 (0) 83% (10) 8% (1) 8% (1)
Table 5
Black et al OiP Submission 2017 12
NB. Respondent could select more than one option
Before LES training, did you repeat a patient’s IOPs if found to be >21mmHg?
% (n)
After LES Training, do you repeat a patient’s
IOPs if found to be >21mmHg?
% (n)Never 0% (0) 0% (0)
Sometimes with a NCT
17% (2) 8% (1)
Usually with a NCT 25% (3) 8% (1)
Usually with a CT 0% (0) 33% (4)
Always with a NCT 67% (8) 50% (6)
Always with a CT 0% (0) 42% (5)
In the final question clinicians were asked to comment on what impact, if any, they
felt the LES training had on their clinical assessment for signs of glaucoma. Seventy-
five percent (n=9) reported that LES training had improved aspects of their clinical
practice, 17% (n=2) reported very little impact and 8% (n=1) reported no
improvement. Seventeen percent (n=2) of the respondents noted that even with the
training they still did not feel confident in performing contact tonometry.
Stage 3- Survey of all LES accredited optometrists
ParticipantsOver 350 optometrists had received LES accreditation in Northern Ireland at the time
when the survey was launched. Valid email addresses were available for 341
accredited optometrists, 110 completed the survey representing a 32% participation
rate. Participants had the option at the end of the survey to provide details on the
following:
year of professional qualification
primary place of work
additional qualifications
Black et al OiP Submission 2017 13
The information collected has been summarised in Table 6.
Table 6
No. of respondents (n)
Details
Qualifying year 70 51% 2000-200923% 1990-199911% 1980-19899% 2010-20156% 1970 -1979
Primary place of work(May be split between more than one sector)
69 55% Independent38% Multiple4% Locum4% University2% Hospital
Additional qualifications 32 38% Professional Certificate in Glaucoma22% None13% Professional Certificate in Medical Retina 9% Independent Prescribing6% Ocular Therapeutics6% Diploma in cataract and refractive surgery3% Diploma in School Vision 3% Diploma in Sport Vision 3% MPhil 3% MSc3% PhD
Survey Responses
Black et al OiP Submission 2017 14
Compulsory QuestionsBefore/after receiving LES training, did/do you use a volk lens and slit lamp to
examine the optic disc?
Figure 5 shows the distribution of respondents’ use of a volk lens and slit lamp when
examining the optic disc before and after receiving LES training. The majority of
respondents reported that they “sometimes” used a volk lens to assess the optic disc
before receiving LES accreditation whereas after training, the majority reported
“always” using indirect ophthalmoscopy. This change, however, was not found to be
statistically significant.
A relatively moderate correlation was found between the year of qualification of the
optometrists and the use of a volk lens to examine the optic disc, with more recently
qualified optometrists likely to use a volk lens both before (rs=.403, p=0.001) and
after (rs=0.342, p=0.005) accreditation.
Black et al OiP Submission 2017
Before LES Training After LES Training
Figure 5
15
Before/after receiving LES training, did/do you assess the depth of a patient's
anterior chamber (ACA) if there was a family history of glaucoma?
Figure 6 displays the optometrists’ responses to the trainings’ impact on their
measurement of the ACA in patients with a FHG. More optometrists report
assessment of the ACA following training. The percentage of those “always”
measuring the ACA is 2.7 times greater following accreditation. This increase in
frequency in ACA assessment was found to be statistically significant (p=0.000,
Mann-Whitney U=3161).
Before/after receiving LES training, what did/do you regularly record when
describing the optic disc?
Figure 7 compares what practitioners would include on patient records when
documenting a description of the optic disc before and after LES training. Although
there is an increase in the percentage of practitioners that record a description of the
NRR and who refer to the ISNT rule when evaluating the optic disc, the difference
was not found to be statistically significant.
Black et al OiP Submission 2017
Before LES Training After LES Training
Figure 6
16
No description CD ratio CD ratio and NRR CD ratio and ISNT Other 0%
10%
20%
30%
40%
50%
60%
70%
0%
16%
58%
17%
8%
0%3%
60%
25%
13%
Before receiving LES training, what did you record in your description of the optic disc After receiving LES training, what do you record in your description of the optic disc
Figure 7
Before/after receiving LES training, did/do you repeat a patient's IOP readings if
found to be over 21mmHg?
Table 7 compares the responses of participants when asked if they repeat IOP
readings if found to be over 21 mmHg before and after accreditation. Respondents
could select multiple responses. The most notable change is the increase in the use
of the CT. Before the training 45% of practitioners stated that they would always
repeat IOP readings with a NCT and 19 % always with a CT if over 21mmHg. After
the training 77% reported always repeating the measurement with a CT and only 9%
always with a NCT. This shift in practitioner instrument choice was found to be
statistically significant (p=0.000; Mann-Whitney U=2691).
Black et al OiP Submission 2017 17
Table 7
IOP reading repeated if initially found to be >21mmHg
Before LES Training % (n)
N=110
After LES Training % (n)N=110
Never 1% (1) 0% (0)
Sometimes with a NCT 6% (7) 4% (4)
Sometimes with a CT 13% (14) 5% (6)
Usually with a NCT 23% (25) 3% (3)
Usually with a CT 9% (10) 14% (15)
Always with a NCT 45% (50) 9% (10)
Always with a CT 19% (21) 77% (85)
Other 2% (2) 3% (3)
Open optional questions
If you do not always use a contact tonometer to repeat IOP measurement since
becoming accredited, please comment why.
Nine participants commented on this section of the survey. Three would repeat IOPs
with a NCT first, if the results were in normal limits, they did not repeat again with a
CT. Two remarked that if there were other signs indicative of glaucoma they would
instead refer via the glaucoma referral pathway. Other reasons why respondents
would not always repeat IOP readings with a CT included; if the patient was already
attending the HES due to raised IOPs, if the practice they were working in was not
registered for the LES scheme and as a CT was the primary method of one
practitioner, they did not need to repeat the readings. One optometrist stated that
although they always repeat IOP measurement with a CT they do not always make a
claim to attain the LES fee as they find the process too difficult.
Black et al OiP Submission 2017 18
What impact, if any, do you feel the LES training has had on your clinical
assessment for the signs of glaucoma?
Eight- two participants completed this question, the answers were analysed using
the online survey’s text analysis function (Ten Kleij 2003) The majority noted a
positive impact in their clinical assessment for the signs of glaucoma, 19% reported
little or no improvement, Table 8.
Table 9 contains a range of the practitioners’ responses.
Table 8
Impact of LES training on clinical assessment for the signs of glaucoma
Percentage %(n)N=82
None 6% (5)
Little improvement 13% (11)
Reduced unnecessary referrals 5% (4)
Formalised Clinical assessment 1% (1)
Raised confidence 11% (9)
Improved clinical assessment 63% (52)
Black et al OiP Submission 2017 19
Table 9: The Impact of training on clinical practice
Black et al OiP Submission 2017
Stage 3- Statistically significant key findings
2.7x more optometrists assessed the ACA in patients with a FHG following LES accreditation.
More recently qualified optometrists are likely to use indirect ophthalmoscopy for ocular examination regardless of training.
More practitioners repeated initially raised IOPs with a contact tonometer following training. 20
Positive Impact ‘it has radically improved my understanding of Glaucoma detection’
‘LES training has improved both my competence and confidence in my clinical assessment for the signs of glaucoma’
‘Has made me assess the disc appearance more carefully and thoroughly, also I always do Van Herick now’
‘Better structure to my investigation and better quality information gathered’
‘More in depth tests before considering referral, less referrals made’
‘I feel more competent at repeating IOPs by a hospital approved method and more confident that I have selected the appropriate referral pathway if required’
‘I feel it has definitely minimised unnecessary referrals to glaucoma services in HES and has made my job feel more worthwhile clinically’
Very Little Impact ‘Very little although I can do goldmann and understand what I am looking for I don’t feel confident in my results as I do it so irregularly’
‘Other than rechecking pressures with contact tonometry not much’
‘I am better informed-but still less than fully competent. However, I still get next to no feedback- so how to improve?’
No Impact ‘I do the same now as before the training’
DiscussionThe current study combines the views of practitioners on the impact of the LES
training scheme along with information taken from patient records. It has been
shown in the literature that clinicians can at times ‘under-record’ the tests that they
carry out (Luck et al. 2000; Shah et al. 2007) and that in questionnaires practitioners
may state that they do more than they do in reality (Franco et al 1997; Shah et al.
2007). This combined approach permits a deeper insight into the ‘real’ effect of
enhanced training on the community optometrist’s routine practice.
Comparison of clinical record review and survey results
Results from Stage 1 and Stage 2 demonstrate that more practitioners use indirect
ophthalmoscopy to examine the optic disc post LES training although this increase
was not found to be statistically significant.
The outcomes from both methods show a significant increase in the assessment of
the ACA by practitioners in patients with a FHG, subsequent to training. In the survey
however, 75% of optometrists reported that they would “usually/always” assess the
ACA in patients with a FHG following accreditation whereas the review of clinical
records showed that only 17% regularly recorded an assessment of the ACA. It is
unclear if this is an example of under-recording or over-reporting in the survey.
IOP measurement
Before practitioners received LES training, contact tonometry was rarely used to
repeat the IOPs of a patient whose initial readings were over 21mmHg.
Results from clinical records and the survey issued in stage 2 and 3 show that the
use of the CT increased following training. There is evidence that some optometrists
still used a NCT alongside a CT to repeat IOP measurements. A lack of confidence
in their contact tonometry results reported by optometrists’ in the open question
section of the survey may account for this.
Trends
Recently qualified optometrists are more likely to use indirect ophthalmoscopy
compared with more experienced practitioners. This is possibly due to universities
Black et al OiP Submission 2017 21
like Ulster University encouraging students to use indirect ophthalmoscopy as part of
their routine ocular assessment.
Following training 2.7x more optometrists reported assessing the ACA. This may be
as a result of the training package with some optometrists stating that the training
made them do ‘more in depth tests before referral’ and ‘always do Van Herick now’.
Impact of the service
The majority of accredited optometrists surveyed felt the LES training had improved
their clinical assessment for signs indicative of glaucoma and some stated that the
training increased their confidence.
A report released in November 2015 from Northern Ireland’s Health and Social Care
Board (HSCB 2015) showed that since the introduction of the LES scheme, 65%
(n=2237) of patients who initially presented with IOPs >21mmHg were not referred
after referral refinement reducing the number of referrals and burden onto the HES.
The report also included an audit of referrals that had been sent to the Belfast Health
and Social Care Trust in a three week period during March 2015 via the referral
refinement scheme. The audit showed that there was still a significant percentage
(36%) of false positives.
The views of the optometrists from the current study agree with Konstantakopoulou
et al. (2014) in which all of optometrists working within a Glaucoma Referral
Refinement Scheme (GRRS) in Manchester felt that their glaucoma detection skills
had improved significantly, particularly in the recognition of false positive cases. The
need for more specific feedback from the hospital to improve future referrals was
brought to light by some of the surveyed Northern Ireland optometrists. This is
something that has also been identified in other studies (Konstantakopulou et al.
2014; Needle et al. 2008; Whittaker et al. 1999). GRRS optometrists in Manchester
did receive feedback from their referrals, reporting that they valued both the quality
and frequency of the feedback (Konstantakopoulou et al. 2014).
Northern Ireland’s Health and Social Care Board hopes to further reduce false
positives by the introduction of LES II for glaucoma (HSCB 2016). Practitioners
wishing to participate in LES II will be required to have the College of Optometrists
Professional Certificate in Glaucoma and attend training provided by the board on
LES II protocol. LES II practitioners will be expected to carry out the following clinical
tests on eligible patients:
Black et al OiP Submission 2017 22
i. IOP measurement via CT
ii. Anterior chamber assessment and estimate of angle width.
iii. Dilated optic nerve assessment with binocular indirect ophthalmoscopy
iv. Central threshold automated perimetry
Eligible patients include those with one or more of the following clinical signs:
i. Patients with IOPs above the normal range for their age when repeated with
applanation tonometry (LES I)
ii. A repeatable visual field defect/loss with normal IOP and normal optic disc
appearance.
iii. IOPs outside age- related range and a suspicious optic disc appearance with
normal visual fields
iv. Anterior segment signs of secondary glaucoma with IOPs outside age-related
range.
After the additional assessment the LES ll accredited optometrist has more clinical
freedom to continue to manage the patient within primary care in the absence of
definitive evidence of glaucoma.
Areas of further research
Once LES II has been introduced to Northern Ireland a similar audit should be
employed to assess the number of false positives referred to the HES and the impact
LES II has on not only the optometrists involved but all key stakeholders.
Conclusion
This study shows that optometrists report finding additional training beneficial to their
clinical practice can be successfully trained to reduce false positive ocular
hypertensive referrals.
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