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Glaucoma: diagnosis and management. London: National Institute for Health and Care Excellence (NICE); 2017 Oct. (NICE Guideline, No. 81.)
This publication is provided for historical reference only and the information may be out of date.
11.1. Service models for case finding, referral filtering and diagnosis
11.1.1. Introduction
False-positive referrals are inconvenient for the individuals referred and create unnecessary anxiety. In addition, these referrals put unnecessary strain on Health Services in terms of wasted cost and high demands on a limited outpatient resource. For these reasons, some regions have adopted ‘Referral Filtering’ models to improve the accuracy of referrals to secondary eye services. These include:
- Repeat measures schemes – Repeating the intraocular pressure measurement on the same visit or on another occasion (by use of the reference standard Goldmann Applanation tonometer or Perkins hand-held tonometer), and sometimes also repeating a suspect visual field assessment
- Enhanced case finding – A more in-depth assessment is carried out specifically for the detection of glaucoma. This process may include history taking, repeating measurements as above and the addition of further examination techniques or investigations
- Referral refinement – The assessment includes all the necessary examination techniques and tests sufficient to make a diagnosis of OHT and suspected COAG and formulation of a clinical management plan.
11.1.2. Review question: What is the clinical and cost-effectiveness of performing different tests or combinations of tests (including repeat measures of individual tests) for identifying people who require onward referral from the first contact with primary care to a confirmed diagnosis?
For full details, see review protocol in appendix C.
Table 90
PICO characteristics of review question.
11.1.3. Clinical evidence
No relevant randomised controlled trials or cohort studies were identified that compared service models for identifying people who require onward referral from first contact primary care to confirming diagnosis. See also the study selection flow chart in appendix E, forest plots in appendix K, study evidence tables in appendix H, GRADE tables in appendix J and excluded studies list in appendix L.
11.1.4. Economic evidence
Published literature
Three health economic studies were identified with the relevant comparison and have been included in this review.10, 114, 116 These are summarised in the health economic evidence profile below (Table 32) and the health economic evidence tables in appendix I.
One economic study relating to this review question was identified but was excluded due to limited applicability.33 This is listed in appendix M, with the exclusion reason provided.
See also the health economic study selection flow chart in appendix F.
Table 91
Health economic evidence profile: triaging or refinement services versus each other, no refinement, or current practice.
Supporting evidence
An additional study was identified in the review of health economic evidence,56 but as the study did not include any comparators – it only analysed 1 service model – it could not be included as evidence for this review. The study results were presented as supporting evidence for the implementation of referral refinement prior to referral to Hospital Eye Services (HES).
Henson (2003)56 analysed the implementation of a Manchester-based referral refinement scheme designed to reduce the number of false-positive referrals to the HES. “Patients with suspected glaucoma, instead of being referred to their GP and then on to the hospital eye service, were referred to a group of specially trained community optometrists working to an agreed set of referral criteria. Those patients who did not meet the referral criteria were returned to the referring optometrist, while those who met the referral criteria were referred directly to Manchester Royal Eye Hospital. The patient’s GP was informed in all cases. The number of suspect glaucoma cases referred to the Manchester Royal Eye Hospital was reduced by 40%. This figure is close to the percentage of false-positive referrals measured at Manchester Royal Eye Hospital prior to the onset of this study. The information accompanying referral has been improved and the scheme produces a small financial cost saving to the NHS of approximately £17 per patient.”56
New cost-effectiveness analysis
This area was not prioritised for new cost-effectiveness analysis.
11.1.5. Evidence statements
Clinical
No relevant clinical studies were identified.
Economic
- One cost-utility analysis found that setting up a hospital triage process prior to people having a clinical examination by a clinician was cost effective compared to having no triage process in place. The most cost effective triage process was to use GDx in the triage tests however this type of imaging test was not a test included in the review protocol. This study was assessed as directly applicable with potentially serious limitations.
- One comparative cost analysis found that setting up referral filtering schemes in the community (repeat measures or enhanced case finding) could decrease costs per patient compared to having no referral filtering in place and could significantly decrease the number of referrals to hospital eye services(HES). This study was assessed as directly applicable with potentially serious limitations.
- One cost-effectiveness analysis found that giving everyone tonometry testing in the community versus doing tonometry to high-risk individuals only cost £656.25 per extra year of vision saved and £3,000 per extra person prevented from going blind. This study was assessed as partially applicable with potentially serious limitations.
11.1.6. Recommendations and link to evidence
| Recommendations |
|
| Relative values of different outcomes | The committee agreed that the critical outcomes were the effects of the accuracy of various service models such as appropriate referral or non-referral, missed OHT, suspect COAG or COAG, and vision loss as a result of incorrect non-referral. Other outcomes that were considered important were long-term visual field loss (measured as a continuous outcome) or the dichotomous outcome of change from normal visual field to visual field defect, long-term optic nerve head damage (measured as a continuous outcome) or the dichotomous outcome of change from normal or suspicious to abnormal optic nerve head, health-related quality of life and participant satisfaction reported on validation scores. |
| Quality of the evidence | No clinical evidence was identified for inclusion in this review. |
| Trade-off between clinical benefits and harms | Hospital Eye Care Services (HES) are currently struggling to find the capacity to see the large numbers of people referred from primary and community services; these people are referred largely based on single readings of IOP (above the CG85 recommended treatment threshold of 21 mmHg). When there is no referral filtering system in place, roughly 30%-40% of people referred are discharged after the first visit. Another 30%-40% of those who return due to uncertain visual fields will then be discharged on the second or third visit. Similar to other physiological measurements, IOP fluctuates both throughout the day (short-term) and from day-to-day (long-term) and, as such, there can be considerable measurement noise surrounding IOP measurement.140,
142 Due to the dynamic nature of IOP, as well as other ocular parameters that can cause erroneous IOP measurements (for example, CCT), single IOP measurement techniques only provide an estimate at a given moment in time and may lead to over- or under-estimations of IOP. Repeat measures Recommending repeat measures prior to referral would have a significant impact on the numbers of people referred into secondary eye care services for confirmation of diagnosis and treatment implementation. This would reduce costs to the NHS and free up capacity in the HES. In the context of primary care optometry a simple repeat measures scheme may involve repeating IOP measurement when prior non-contact tonometry readings indicate an IOP of 24 mmHg or above. Other repeat measures schemes may also involve repeating visual field measurements.27, 70 The committee decided to make a consider recommendation, as no strong evidence was found. The committee did specify ‘on another occasion’ to highlight that the repeated measures should not be conducted all in the same visit with respect to the dynamic nature of IOP and the associated measurement noise. If clinical circumstances indicate urgent or emergency referral is required then repeating tests may not be needed if it would slow down the referral. Goldmann-type applanation tonometrv The committee recommended that Goldmann-type applanation tonometry should be included in any service model before referral. This was because the results of GAT are more reliable than non-contact tonometry. Please see the chapter on case finding for further discussion on this. Referral filtering There was no clinical evidence identified comparing different models for organising case-finding and diagnosis services and the impact different referral pathways may have on the health benefits for patients. However, some applicable cost effectiveness evidence was identified and is discussed in the next section. The committee highlighted the 2016 NICE accredited Commissioning Guide for Glaucoma27, 70 that offers definitions for some of the ways in which glaucoma services could be arranged at the local level in order to provide referral filtering with the aim of relieving capacity issues in the Hospital Eye Care Service (HES). These include repeat measures (discussed above), enhanced case finding and referral refinement. Enhanced case finding refers to the use of specific tests such as slit-lamp mounted Goldmann applanation tonometry and dilated slit-lamp indirect biomicroscopy performed prior to referral to confirm abnormal results identified at case finding. Referral refinement describes a two-tiered assessment pathway where any initially concerning result picked up at the case-finding stage (tier 1) is validated by a subsequent enhanced assessment (tier 2). This second tier is a step up from a simple repeat measures scheme in that the clinician providing the referral refinement service must be qualified to make a diagnosis of OHT and suspected glaucoma and to carry out gonioscopy to exclude angle-closure glaucoma. The 3 referral filtering systems27, 70 each involve different arrangements of repeat testing, different levels of clinical skill and qualification required for using some of the specific tests, and can occur in different contexts along the patient pathway (community or primary eye care services, or in-hospital triage). The committee believed that in many locations around the UK some form of these referral-filtering systems was already in place. In light of the economic evidence and the committee’s experience and knowledge of existing local arrangements, the committee decided to recommend that those who organise and commission glaucoma services consider providing some form of referral-filtering service to improve the accuracy of referrals and address current HES capacity issues. Further discussion on the possible cost-saving implications of such arrangements is in the following section. Providing results with the referral The committee made a strong recommendation that services should be set up to ensure that the results of all examinations and tests should be provided with the referral. This is to ensure that the healthcare professional receiving the patient is aware of previous results and the reasons for referral. Discharge summary The committee recommended that a discharge summary is given to people who have been assessed and discharged to primary care. A copy should be sent to their GP and, with patient consent, a copy of the relevant information to the primary eye care professional nominated by the patient. People should be advised to take their discharge summary with them when attending future sight tests. The committee considered that this may help to prevent patients being re-referred unnecessarily. |
| Trade-off between net clinical effects and costs | Three economic evaluations were identified for this review plus 1 study that was presented as supporting evidence. The cost-utility analysis10 estimated that having a hospital triage process in place where optic nerve head imaging, IOP and visual tests are performed by nurses and technicians prior to people either being seen for a full examination by a clinician or discharged, would be cost saving compared to not having a hospital triage process in place. All 4 triage strategies compared in the study reduced costs; however, they all also reduced health outcomes due to the imperfect accuracy of the tests used to triage. The most cost-effective strategy was to use GDx and then HRT-MRT and then OCT to image the optic nerve head however, GDx was not included in the review protocol and the committee discussed the issue that HRT technology was becoming less widely used due to manufacturing and maintenance issues and was likely to be disestablished in the near future. The same study reported that current practice dominates all strategies under the plausible assumption that an NHS provider of care would charge, for the triage station, an NHS reference cost tariff corresponding to an outpatient appointment. The committee therefore decided not to recommend triaging using imaging in a diagnosis setting. The comparative cost analysis114 suggests that implementing enhanced glaucoma referral schemes (repeat measures or referral refinement) could reduce mean costs per patient and could significantly reduce the number of people referred to hospital eye services (HES), compared to the numbers likely to be referred without any referral filtering scheme in place. The study was unable to analyse the diagnostic accuracy and whether they would increase the number of false negative diagnoses, as fewer people would be referred onwards for a full examination by a consultant ophthalmologist. The study also assumed that without a scheme in place, community optometrists would refer everyone suspected of having a COAG related condition directly to HES and costed this scenario. For these reasons, this study was rated as having potentially serious limitations as any interpretation would need to have these caveats in mind. They did not base the ‘no scheme’ cost on data as everyone referred in the area over the study period were all referred via 1 of the 2 schemes. The committee mentioned that in areas where there is no referral filtering in place, roughly 30%-40% of people are discharged at their first HES appointment as false positive referrals. The committee felt that as people referred through a scheme would have had a more thorough investigation, it would not be likely that the schemes would increase the number of false negatives (even if fewer people are examined by a HES clinician), but it would be likely that referral-filtering schemes would decrease the number of false positives referred to HES. As HES is currently experiencing significant issues regarding capacity constraints, the committee felt that it was important that people planning eye care services consider providing referral filtering schemes such as repeat measures by optometrists to reduce the number of false positive referrals. Although having referral filtering in place would increase costs, these would most likely be offset by reductions of costs due to less referrals to HES. This would be likely to reduce costs to the NHS and unlikely to increase the risks to patients. In order for referral filtering schemes to work and ensure wide participation from community optometrists, the committee noted that there must be reimbursement mechanisms in place for tests performed in addition to what is required in NHS sight tests, as well as any repeat measure tests or additional assessments performed prior to onward referral. How areas model the service delivery of the new recommendations will depend on what type of referral filtering models they decide to implement in accordance with what model they believe will work best in that particular area. Recommending that all people receive an IOP measurement using Goldmann-type applanation tonometry does not mean that all community optometrists need to invest in the equipment needed to perform Goldmann-type applanation (a large proportion will already have the equipment). However, it does require that optometrists that do not use Goldmann-type applanation (for example, if they use a non-contact test) will need to refer people suspected of OHT on to an enhanced case finding or referral refinement service, where they will receive GAT prior to an onward referral to HES. The cost-effectiveness analysis study from the Netherlands116 estimated that routinely performing GAT for all people aged at least 40 years visiting an ophthalmic practice cost an additional £3,500 per person avoided becoming blind, and an additional £656.25 per year of vision saved (over a 20 year time horizon), compared to only performing GAT on people considered to be high risk. This study was rated as partially applicable with potentially serious limitations, as it is not a UK study and the outcomes are difficult to interpret because it is not a cost-utility analysis. The committee did not recommend that everyone who goes for an eye test should receive a GAT test, as this would have a significant cost impact to community optometrists who do not already have the equipment and to the NHS who would need to reimburse optometrist for all the GAT tests performed. However, the evidence does support the recommendation that Goldmann-type applanation should be performed on everyone being considered for an onward referral to diagnosis. The committee also highlighted some additional research by Ratnarajan et al. (2013)121 that supports implementing referral filtering models prior to referral to HES. |
| Other considerations | Various forms of referral filtering schemes are currently in place throughout the country, for example, Manchester and Bexley. |
11.2. Skills required by healthcare professionals
11.2.1. Introduction
The majority of patients in the UK who develop COAG are initially identified when they present to their own optometrist for routine eye examination. Optometrists employ a case-finding approach to identifying individual patients who either exhibit signs consistent with COAG, or appear to be at risk of COAG development. Traditionally, individuals identified in this manner are then referred, via their General Practitioner, for comprehensive specialist examination by Ophthalmologists within the Hospital Eye Service (HES). Within the HES setting, patients receive a formal diagnosis and ongoing management, if required, by ophthalmology staff. Patients with no evidence of COAG are typically discharged, whilst those diagnosed with COAG receive appropriate treatment and ongoing monitoring. Individuals with ocular hypertension or COAG suspect status that are considered at sufficient risk of COAG development receive either treatment and HES monitoring, HES monitoring alone or discharge, dependent upon the specific clinical scenario of risk of COAG development.
Over the past decade, increasing demand for care of patients with COAG, ocular hypertension and COAG suspect status has led to involvement of non-medical and non-ophthalmologist medical healthcare professionals in COAG care beyond traditional roles. NHS service developments have also supported and encouraged changes to provision of COAG care. This has resulted in deviations from the traditional patient pathway in which non-ophthalmologist healthcare professionals participate in roles previously undertaken by ophthalmologists. In some locations, revised pathways now provide for parts of COAG-related patient care in non-HES locations. In the future it is possible that an increasing proportion of these patients will need to be managed by non-medical and nonophthalmologist healthcare professionals to meet the burgeoning demands on COAG service provision.
In this section, we examine evidence on effectiveness of care delivered by different healthcare professionals. For the purposes of this guideline the term ‘healthcare professional’ refers to a trained individual involved in glaucoma related care including: ophthalmologists, optometrists, orthoptists, pharmacists, nurses and general practitioners. We have reviewed the evidence for diagnosis, monitoring and treatment
11.2.2. Matrices of healthcare professionals considered in our clinical questions
Below are the matrices showing where evidence was identified which compared agreement between different groups of healthcare professionals in the management of ocular hypertension and COAG. A box filled with Yes represents where evidence was found and is reviewed in this chapter. A box filled with No represents where no evidence was found or where the resulting statistical measure for agreement between comparisons was less than moderate. In this case no section on this comparison is included in the chapter. A box crossed out represents where the comparison was not considered for review.
Matrix 1
Effectiveness of diagnosis by different healthcare professionals.
Matrix 2
Effectiveness of monitoring by different healthcare professionals.
Matrix 3
Effectiveness of treatment by different healthcare professionals.
11.2.3. Effectiveness of diagnosis by different healthcare professionals
We searched for any studies comparing the agreement in the diagnosis of ocular hypertension or COAG between the different groups of healthcare professionals listed in the matrix at the beginning of this chapter. We did not compare agreement within groups.
11.2.3.1. Non specialist optometrist compared to general ophthalmologist
See the study evidence tables in appendix H.
11.2.3.2. Clinical evidence
Table 92
Non-specialist optometrist compared to general ophthalmologist - Clinical study characteristics.
Table 93
Non-specialist optometrist compared to general ophthalmologist - Clinical summary of findings.
11.2.3.3. Economic evidence
No studies were identified.
11.2.3.4. Patient views evidence
No studies were identified.
11.2.3.5. Evidence statements - Non specialist optometrist compared to general ophthalmologist
| Clinical | There is fair to moderate agreement between non-specialist optometrists and general ophthalmologists in assessment of vertical cup-to-disc ratio assessment but the evidence is from retrospective examination from stereo photograph pairs. (LOW QUALITY) There is moderate to substantial agreement between non-specialist optometrists and general ophthalmologists in detecting the presence of optic disc haemorrhage but the evidence is from retrospective examination from stereo photograph pairs. (LOW QUALITY) |
|---|---|
| Economic | No studies meeting the inclusion criteria were identified which compared non-specialist optometrist to general ophthalmologist. |
11.2.4. Non specialist optometrist compared to specialist ophthalmologist
See the study evidence tables in appendix H.
11.2.4.1. Clinical evidence
Table 94
Non-specialist optometrist compared to specialist ophthalmologist - Clinical study characteristics.
Table 95
Non-specialist optometrist compared to specialist ophthalmologist - Clinical summary of findings.
11.2.4.2. Economic evidence
No studies were identified.
11.2.4.3. Patient views evidence
No studies were identified.
11.2.4.4. Evidence statements - Non specialist optometrist compared to specialist ophthalmologist
| Clinical | There is substantial agreement on the kappa scale between non-specialist optometrists with in-house training and specialist ophthalmologists in diagnostic management decisions from all test results. (MODERATE QUALITY) There is almost perfect agreement on the kappa scale between non-specialist optometrists with in-house training and specialist ophthalmologists in assessment of vertical cup-to-disc ratio. (MODERATE QUALITY) There is substantial agreement on the kappa scale between non-specialist optometrists with in-house training and specialist ophthalmologists in detecting the presence of optic disc haemorrhage. (MODERATE QUALITY) There is substantial agreement on the kappa scale between non-specialist optometrists with in-house training and specialist ophthalmologists in assessment of overall health status of the optic nerve head. (MODERATE QUALITY) |
|---|---|
| Economic | No studies meeting the inclusion criteria were identified which compared non-specialist optometrists to specialist ophthalmologists. |
11.2.5. Specialist ophthalmologist compared to general ophthalmologist
See the study evidence tables in appendix H.
11.2.5.1. Clinical evidence
Table 96
Specialist ophthalmologist compared to general ophthalmologist - Clinical study characteristics.
Table 97
Specialist ophthalmologist compared to general ophthalmologist - Clinical summary of findings.
11.2.5.2. Economic evidence
No studies were identified.
11.2.5.3. Patient views evidence
No studies were identified.
11.2.5.4. Evidence statements - Specialist ophthalmologist compared to general ophthalmologist
| Clinical | There is moderate agreement on the kappa scale between specialist ophthalmologists and general ophthalmologists in diagnostic management decisions from all test results. (MODERATE QUALITY) |
|---|---|
| Economic | No studies meeting the inclusion criteria were identified which compared specialist ophthalmologists to general ophthalmologists. |
11.2.6. General ophthalmologist compared to certified optometrist with a special interest
See the evidence tables in appendix I.
11.2.6.1. Clinical evidence
No studies were identified.
11.2.6.2. Economic evidence
We found a cost analysis comparing a referral refinement scheme to normal practice in the UK. Patients in the scheme are referred from a community optometrist to an optometrist with a special interest who decides whether the patient needs to be referred to the Hospital Eye Service. In the comparative normal practice arm, patients are referred directly from the community optometrist to the Hospital Eye Service via a GP. See the economic evidence tables in appendix I for details.
Table 98
General ophthalmologist compared to certified optometrist with a special interest -Economic study characteristics.
Table 99
General ophthalmologist compared to certified optometrist with a special interest -Economic summary of findings.
11.2.6.3. Patient views evidence
No studies were identified.
11.2.6.4. Evidence statements - General ophthalmologist compared to certified optometrist with a special interest
| Clinical | No studies were identified where the statistical agreement between general ophthalmologist and certified optometrist with a specialist interest was either moderate or better. |
|---|---|
| Economic | Referring patients to accredited optometrists could decrease costs compared to a direct referral to ophthalmologists. The evidence has serious limitations and only partial applicability. |
11.2.7. Recommendations and link to evidence
| Recommendation |
|
| Relative values of different outcomes | Accurate measurement of visual field, optic nerve, IOP and the anterior chamber drainage angle are all considered as equally important outcomes because COAG is defined by all four. Further studies are needed to show agreement between different types of clinicians in the assessment of these parameters. |
| Trade off between clinical benefits and harms | Patients may receive their diagnosis sooner if evaluated in a community setting. Diagnosis of OHT and COAG suspects by staff other than consultant ophthalmologists may increase access to consultants’ care for patients requiring formal COAG diagnosis. Refer to section 1.8 in appendix U for assumptions for OHT and COAG suspect. |
| Economic considerations | Diagnosis by healthcare professionals other than ophthalmologists could be cost saving even when the cost of referrals to ophthalmologists is taken into account. |
| Quality of evidence | The clinical evidence was of variable quality due to the following limitations: studies were not carried out in a systematic and controlled way, and there was the potential for selection bias, as some patients were volunteers. The economic evidence has serious limitations because the only study identified was not a full economic evaluation, the cost of false negatives were not estimated and the capital cost of necessary equipment for accredited optometrists was not included. The economic evidence has partial applicability, as it does not directly answer the clinical question. |
| Other considerations | Although not addressed as a clinical question the GDG noted that there is not always a high level of agreement between specialist ophthalmologists. However specialist ophthalmologists are considered to be the reference standard in this review. Therefore, the reliability of our reference standard could be questionable. Evidence is only available for optometrists, with no studies available for other non-medical healthcare professionals or non-ophthalmologist medical staff. The GDG noted that the correct equipment to complete diagnostic assessments in keeping with the reference standards for tonometry, standard automated central thresholding perimetry and biomicroscopic slit lamp examination are required for healthcare professionals to perform diagnosis in a community setting and should be available. Patient preference for assessment at hospital or in the community should be considered. |
11.2.8. Supporting recommendations
| Recommendation |
|
| Trade off between clinical benefits and harms | The consequence of either failing to identify COAG or incorrect diagnosis may lead to irreversible blindness and visual disability. |
| Economic considerations | There are high costs associated with false negative and false positive diagnoses of COAG. It is important to obtain the most accurate diagnosis. |
| Other considerations | None |
| Recommendation |
|
| Trade off between clinical benefits and harms | Training is likely to improve quality of care by increasing the healthcare professional’s knowledge of discriminatory power (sensitivity and specificity). |
| Economic considerations | None |
| Other considerations | The GDG noted that the correct equipment to complete diagnostic assessments in keeping with the reference standards for tonometry, standard automated central thresholding perimetry and biomicroscopic slit lamp examination are required for healthcare professionals to perform diagnosis in a community setting and should be available. |
11.3. Effectiveness of monitoring by different healthcare professionals
We searched for any studies comparing the agreement in the monitoring of ocular hypertension or COAG between the different groups healthcare professionals listed in the matrix at the beginning of this chapter. We did not compare agreement within groups.
11.3.1. Non specialist optometrist compared to general ophthalmologist
See the study evidence tables in appendix H and the economic evidence in appendix I.
11.3.1.1. Clinical evidence
Table 100
Non-specialist optometrist compared to general ophthalmologist - Clinical study characteristics.
Table 101
Non-specialist optometrist compared to general ophthalmologist - Clinical summary of findings.
11.3.1.2. Economic evidence
We found a UK study where patients with COAG were randomised to either follow-up by the Hospital Eye Service or community optometrists. See economic evidence tables in appendix I for details.
Table 102
Non-specialist optometrist compared to general ophthalmologist - Economic study characteristics.
Table 103
Non-specialist optometrist compared to general ophthalmologist - Economic summary of findings.
11.3.1.3. Patient views evidence
No studies were identified.
11.3.1.4. Evidence statements - Non specialist optometrist compared to general ophthalmologist
| Clinical | There is almost perfect and substantial agreement on the kappa scale between non-specialist optometrists and general ophthalmologists in visual field assessment for the right and left eyes respectively. (MODERATE QUALITY) There is almost perfect agreement on the kappa scale between non-specialist optometrists and general ophthalmologists in follow-up intervals. (MODERATE QUALITY) There is moderate and substantial agreement on the ICC scale between non-specialist optometrists with in-house training and general ophthalmologists in visual field assessment for the right and left eyes respectively. (HIGH QUALITY) There is moderate and substantial agreement on the ICC scale between non-specialist optometrists with in-house training and general ophthalmologists in assessment of vertical cup-to-disc ratio for both eyes. (HIGH QUALITY) There is moderate and fair agreement on the ICC scale between non-specialist optometrists with in-house training and general ophthalmologists in IOP measurement for the right and left eyes respectively. (HIGH QUALITY) There is fair to moderate agreement between non-specialist optometrists and general ophthalmologists in assessment of vertical cup-to-disc ratio assessment but the evidence is from retrospective examination from stereo photograph pairs. (LOW QUALITY) There is moderate to substantial agreement between non-specialist optometrists and general ophthalmologists in detecting the presence of optic disc haemorrhage but the evidence is from retrospective examination from stereo photograph pairs. (LOW QUALITY) |
|---|---|
| Economic | Monitoring by non-specialist optometrist is more costly than monitoring by general ophthalmologist unless the follow-up intervals are similar. The evidence has serious limitations and partial applicability. |
11.3.2. Recommendations and link to evidence
| Recommendation |
|
| Relative values of different outcomes | The most important aspects of monitoring are: Progression Detection of changes in clinical status Diagnosis, including being alert to ocular and systemic comorbidities Starting treatment Changing treatment Tests at each visit Follow up interval |
| Trade off between clinical benefits and harms | Factors to be considered during monitoring are: Prevention of sight loss Side effects of treatment Interactions with other medications Incorrect treatment (absent or inadequate) leading to sight loss Incorrect diagnosis leading to sight loss Incorrect diagnosis leading to over treatment |
| Economic considerations | Monitoring by trained healthcare professionals other than ophthalmologists could be cost saving even when the cost of referrals is taken into account. |
| Quality of evidence | The clinical evidence was of variable quality due to the following limitations: studies were not carried out in a systematic and controlled way, and there was the potential for selection bias, as some patients were volunteers. The economic evidence has serious limitations and partial applicability because the only study identified was not a full economic evaluation, the cost of false positives and false negatives was not included, and there was potential selection bias, as some patients were volunteers. The optometrists in the study were volunteers. The study was a shared care scheme rather than a comparison between the care of two alternative healthcare professionals. |
| Other considerations | Specialist ophthalmologists are considered to be the reference standard in this review. Although not addressed as a clinical question the GDG noted that there is not always a high level of agreement between specialist ophthalmologists themselves. Evidence is only available for optometrists, with no studies available for other non-medical healthcare professionals or non-ophthalmologist medical staff. The GDG noted that the correct equipment to complete diagnostic assessments in keeping with the reference standards for tonometry, standard automated central thresholding perimetry and biomicroscopic slit lamp examination are required for healthcare professionals to perform diagnosis in a community setting and should be available. Patient preference for assessment at hospital or in the community should be considered. |
11.4. Effectiveness of treatment by different healthcare professionals
We searched for any studies comparing the agreement in the decisions to treat patients with ocular hypertension or COAG between the different groups healthcare professionals listed in the matrix at the beginning of this chapter. We did not compare agreement within groups.
11.4.1. Non specialist optometrist compared to general ophthalmologist
See the study evidence tables in appendix H.
11.4.1.1. Clinical evidence
Table 104
Non-specialist optometrist compared to general ophthalmologist - Clinical study characteristics.
Table 105
Non-specialist optometrist compared to general ophthalmologist - Clinical summary of findings.
11.4.1.2. Economic evidence
No studies were identified.
11.4.1.3. Patient views evidence
No studies were identified.
11.4.1.4. Evidence statements - Non specialist optometrist compared to general ophthalmologist
| Clinical | There is substantial agreement on the kappa scale between non-specialist optometrists with in-house training and general ophthalmologists in decision to treat. (MODERATE QUALITY) There is perfect and almost perfect agreement on the kappa scale between non-specialist optometrists and general ophthalmologists in treatment decisions (start/increase/reduce) for the right and left eyes respectively. (MODERATE QUALITY) |
|---|---|
| Economic | No studies meeting the inclusion criteria were identified which compared non-specialist optometrists to general ophthalmologists. |
11.4.2. Non specialist optometrist compared to specialist ophthalmologist
See the study evidence tables in appendix H.
11.4.2.1. Clinical evidence
Table 106
Non-specialist optometrist compared to specialist ophthalmologist - Clinical study characteristics.
Table 107
Non-specialist optometrist compared to specialist ophthalmologist - Clinical summary of findings.
11.4.2.2. Economic evidence
No studies were identified.
11.4.2.3. Patient views evidence
No studies were identified.
11.4.2.4. Evidence statements - Non specialist optometrist compared to specialist ophthalmologist
| Clinical | There is substantial agreement on the kappa scale between non-specialist optometrists with in-house training and specialist ophthalmologists in decision to treat. (MODERATE QUALITY) |
|---|---|
| Economic | No studies meeting the inclusion criteria were identified which compared non-specialist optometrists to specialist ophthalmologists. |
11.4.3. Specialist ophthalmologist compared to general ophthalmologist
See the study evidence tables in appendix H.
11.4.3.1. Clinical evidence
Table 108
Specialist ophthalmologist compared to general ophthalmologist - Clinical study characteristics.
Table 109
Specialist ophthalmologist compared to general ophthalmologist - Clinical summary of findings.
11.4.3.2. Economic evidence
No studies were identified.
11.4.3.3. Patient views evidence
No studies were identified.
11.4.3.4. Evidence statements - Specialist ophthalmologist compared to general ophthalmologist
| Clinical | There is moderate agreement on the kappa scale between specialist ophthalmologists and general ophthalmologists in decision to treat. (MODERATE QUALITY) There is moderate agreement on the kappa scale between specialist ophthalmologists and general ophthalmologists in treatment decisions (start/increase/reduce). (MODERATE QUALITY) |
|---|---|
| Economic | No studies meeting the inclusion criteria were identified which compared specialist ophthalmologists to general ophthalmologists. |
11.4.4. Specialist ophthalmologist compared to certified optometrist with a special interest
See the study evidence tables in appendix H.
11.4.4.1. Clinical evidence
Table 110
Specialist ophthalmologist compared to certified optometrist with a special interest -Clinical study characteristics.
Table 111
Specialist ophthalmologist compared to certified optometrist with a special interest -Clinical summary of findings.
11.4.4.2. Economic evidence
No studies were identified.
11.4.4.3. Patient views evidence
No studies were identified.
11.4.4.4. Evidence statements - Specialist ophthalmologist compared to certified optometrist with a special interest
| Clinical | There is substantial agreement on the kappa scale between specialist ophthalmologists and certified optometrists with a specialist interest in treatment decisions (start/increase/reduce). (MODERATE QUALITY) |
|---|---|
| Economic | No studies meeting the inclusion criteria were identified which compared specialist ophthalmologists to certified optometrists with a special interest. |
11.4.5. Recommendations and link to evidence
| Recommendation |
|
| Relative values of different outcomes | Treatment decisions are dependent upon: Diagnosis, including being alert to ocular and systemic comorbidities Severity of COAG or level of conversion risk Effectiveness, contra-indications, precautions and interactions of existing anti-COAG medications Tolerance of current anti-COAG medications Systemic conditions and medications |
| Trade off between clinical benefits and harms | Treatment by non-medical healthcare professionals or non-ophthalmologists will increase the number of healthcare professionals available from which care may be accessed. |
| Economic considerations | None |
| Quality of evidence | The clinical evidence was of moderate quality. Studies were not carried out in a systematic and controlled way and there was the potential for selection bias, as some patients were volunteers. |
| Other considerations | There are not enough ophthalmologists at present to do all the work required so the work needs to be shared. Currently hospital lists are full and this results in delayed appointments. Evidence is only available for optometrists, with no studies available for other non-medical healthcare professionals or non-ophthalmologist medical staff. |
11.4.6. Supporting recommendations
| Recommendation |
|
| Trade off between clinical benefits and harms | The committee for the guideline update believed that clarification was needed to specify that practitioners who hold an independent prescribing license are not qualified to manage people being treated for OHT, suspected COAG or COAG unless they also hold a specialist glaucoma-related qualification. They wished to reinforce that the prescribing licence only covers prescribing treatment and does not qualify them to diagnose, assess or manage people on treatment with respect to deciding appropriate reassessment visits for evaluating control of IOP and risk of conversion to or progression of glaucoma. |
| Economic considerations | None |
| Other considerations | None |
| Recommendation |
|
| Trade off between clinical benefits and harms | All clinical tests need to be performed correctly to inform decisions based upon results properly. A clear understanding of the nature of the test and how to interpret results is necessary. Decision-making should be based upon clinical circumstances and current examination. |
| Economic considerations | Training is costly but essential to ensure quality care. |
| Other considerations | Training healthcare professionals takes time. |
| Recommendation |
|
| Trade off between clinical benefits and harms | Clinical governance applies to all NHS services. Although a consultant ophthalmologist may be responsible for the care of a patient they may delegate the task diagnosis, treatment and monitoring to another suitably trained healthcare professional under their supervision. When healthcare professionals provide care independently of consultant supervision they should practice within the limits of their competence. Patients should clearly understand who is responsible for their care. |
| Economic considerations | None |
| Other considerations | None |
- Organisation of care - GlaucomaOrganisation of care - Glaucoma
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