Glaucoma referral and discharge Glaucoma referral and discharge SIGN guidelines SIGN guidelines Roshini Sanders Roshini Sanders Consultant ophthalmologist, Dunfermline Consultant ophthalmologist, Dunfermline Consultant ophthalmologist, Dunfermline Consultant ophthalmologist, Dunfermline (On behalf of the SIGN group) (On behalf of the SIGN group) NES, Glasgow, October 2014 NES, Glasgow, October 2014
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Roshini Sanders - SIGN Guidelines v2 · Glaucoma referral and discharge SIGN guidelines Roshini Sanders Consultant ophthalmologist, Dunfermline (On behalf of the SIGN group) NES,
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Glaucoma referral and dischargeGlaucoma referral and discharge
(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
�� 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
�� 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
�� 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
�� 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
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
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
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.
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 [email protected] 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.