Expanding the traditional role of optometry: Current practice patterns and attitudes to enhanced glaucoma services in Ireland / Ampliar el rol tradicional de la optometría: patrones actuales de práctica y actitudes hacia la mejora de los servicios para glaucoma en Irlanda

Purpose: To investigate current diagnostic equipment availability and usage for glaucoma case-finding within community optometric practice, and to explore optometrists’ attitudes towards an enhanced scope of clinical practice. Methods: An anonymous survey was developed, validated, and distributed to all optometrists in Ireland. Results: 199 optometrists (27% of registrants) responded to the survey. 87% had access to the traditional triad of tests necessary to conduct adequate glaucoma case finding. Standard automated perimetry was the most commonly absent (13%) of the three essential screening tests. 64% of respondents indicated that monocular direct ophthalmoscopy was their first choice technique for fundus examination. 47% of respondents had access to contact applanation tonometry, though just 14% used it as first choice during routine eye examinations. Among the 73 participants with access to both contact and non-contact tonometry (NCT), 80.8%, used NCT preferentially. The significant majority (98%) indicated an interest in enhanced glaucoma services with 57% agreeing that postgraduate training was an essential prerequisite to any increase in scope of practice. Conclusion: Irish optometrists are well equipped with the traditional tests used in glaucoma detection. However, implementation of enhanced referral schemes or glaucoma monitoring or management services would require equipment upgrades and associated training in at least half of the surveyed practices. There is strong interest in furthering optometric professional development and expanding the traditional role boundaries of optometrists, incorporating further education as an essential prerequisite to an enhanced scope of practice

Objetivo: Estudiar la disponibilidad actual y el uso del equipo diagnóstico para la detección de casos de glaucoma dentro de la práctica optométrica comunitaria, y explorar las actitudes de los optometristas hacia la mejora del alcance de la práctica clínica. Métodos: Se desarrolló, validó y distribuyó una encuesta anónima a todos los optometristas de Irlanda. Resultados: 199 optometristas (el 27% de los registrados) respondieron a la encuesta. El 87% tenía acceso a la triada tradicional de pruebas necesarias para realizar una detección adecuada de casos de glaucoma. La perimetría automatizada estándar fue la más comúnmente ausente (13%) de las tres pruebas de cribado esenciales. El 64% de los que respondieron al test indicó que la oftalmoscopia directa monocular era su técnica de primera elección para el examen del fondo del ojo. El 47% de los que respondieron a la encuesta tenía acceso a la tonometría de aplanación de contacto, aunque únicamente el 14% la utilizaba como primera elección durante los exámenes oculares rutinarios. Entre los 73 participantes con acceso tanto a la tonometría de contacto como a la de no contacto (NCT), el 80,8% utilizaban NCT preferentemente. Una mayoría significativa (98%) indicó su interés por mejorar los servicios de glaucoma, el 57% de los cuales afirmó que la formación post-grado era un requisito previo esencial para cualquier incremento del alcance de la práctica. Conclusión: Los optometristas irlandeses están bien equipados de las pruebas tradicionales utilizadas para la detección del glaucoma. Sin embargo, la introducción de programas de mejora de la derivación, o supervisión del glaucoma, o servicios de gestión, requeriría la modernización de los equipos y la formación asociada en al menos el 50% de los encuestados. Existe un fuerte interés por ampliar el desarrollo profesional de la optometría y expandir los límites de la función tradicional de los optometristas, incorporando mayor formación como requisito previo esencial para mejorar el alcance de la práctica

Expanding the traditional role of optometry: Current practice patterns and attitudes to enhanced glaucoma services in Ireland.

PURPOSE: To investigate current diagnostic equipment availability and usage for glaucoma case-finding within community optometric practice, and to explore optometrists' attitudes towards an enhanced scope of clinical practice. METHODS: An anonymous survey was developed, validated, and distributed to all optometrists in Ireland. RESULTS: 199 optometrists (27% of registrants) responded to the survey. 87% had access to the traditional triad of tests necessary to conduct adequate glaucoma case finding. Standard automated perimetry was the most commonly absent (13%) of the three essential screening tests. 64% of respondents indicated that monocular direct ophthalmoscopy was their first choice technique for fundus examination. 47% of respondents had access to contact applanation tonometry, though just 14% used it as first choice during routine eye examinations. Among the 73 participants with access to both contact and non-contact tonometry (NCT), 80.8%, used NCT preferentially. The significant majority (98%) indicated an interest in enhanced glaucoma services with 57% agreeing that postgraduate training was an essential prerequisite to any increase in scope of practice. CONCLUSION: Irish optometrists are well equipped with the traditional tests used in glaucoma detection. However, implementation of enhanced referral schemes or glaucoma monitoring or management services would require equipment upgrades and associated training in at least half of the surveyed practices. There is strong interest in furthering optometric professional development and expanding the traditional role boundaries of optometrists, incorporating further education as an essential prerequisite to an enhanced scope of practice.

Glaucoma referral refinement in Ireland: managing the sensitivity-specificity paradox in optometric practice.

PURPOSE: Glaucoma referral refinement (GRR) has proven a successful demand management strategy for glaucoma suspect cases in the United Kingdom (UK). A GRR clinic was established in Dublin, Ireland to investigate the clinical viability of this pathway outside the UK's National Health Service (NHS) structures, and away from the influence of National Institute for Clinical Excellence (NICE) guidance. METHODS: Glaucoma suspect patients were recruited into the scheme following referral from community optometrists in the greater Dublin area. The GRR exam protocol was designed in consultation with the participating ophthalmology department. The refinement scheme optometrist, trained through apprenticeship style experience at a hospital outpatient clinic, made a tentative management decision after carrying out the GRR exam. The final management decision was made in a 'virtual clinic' by a glaucoma specialist consultant ophthalmologist. RESULTS: Two hundred and twenty-five glaucoma suspect patients were seen in the scheme. After their first GRR visit, 28% were discharged back to their own optometrist, 42% were monitored in the GRR clinic, and 30% were referred to ophthalmology. After this monitoring cohort were further assessed, a total of 38% of the patients seen within the scheme required referral to ophthalmology. Sixteen percent of the total participant group (n = 225) were lost to follow up. Cohen's κ was used to determine the level of agreement between the scheme optometrist and ophthalmologist. There was substantial agreement, with κ = 0.63 for the first visit management decisions (n = 225). Agreement increased for subsequent monitoring visits with κ = 0.85 for second visits (n = 65), and κ = 0.69 for all management decisions within the scheme (n = 301). We received management outcomes for 44 of the 86 patients referred to ophthalmology. Of these 44, 57% received medical treatment for glaucoma, 34% were monitored without treatment, 2% were discharged, and 7% had comorbidities that were assessed and managed. CONCLUSION: Of the patients seen within the scheme, 62% did not require referral onward to ophthalmology, thus releasing the significant majority of hospital clinic slots that would previously have been required to examine such patients. The high level of inter-professional decision agreement likely reflects the benefits of pre-scheme apprenticeship style training and ongoing hospital clinic participation by the scheme optometrist. The rate of loss to follow up compares favourably with ophthalmology led, hospital based, glaucoma clinics. Nevertheless, the losses indicate that patient education remains a key priority for future planning.

Barriers to glaucoma case finding as perceived by optometrists in Ireland.

BACKGROUND: This research was designed to provide an in-depth exploration of the perceptions of optometrists relating to the challenges of glaucoma case finding in the Irish health-care system. METHODS: A survey was developed, piloted and distributed for anonymous completion by optometrists registered to practise in Ireland. The survey included 10 five-level Likert items exploring potential barriers to glaucoma detection and a free-text box for participants to comment more broadly. RESULTS: One hundred and ninety-nine optometrists (27 per cent of registrants) responded to the survey. Among the barriers identified, there was notable agreement (71 per cent) with the need for extra training on glaucoma detection. Logistic regression showed that optometrists without postgraduate qualifications were more likely to agree with the need for extra training (OR 3.2, 95 per cent CI 1.3-8.1). Respondents largely agreed (61 per cent) that patient unwillingness to pay additional fees for supplementary glaucoma-specific tests was also a barrier. Appointment times of less than 30 minutes were significantly associated with six of the 10 proposed barriers to glaucoma detection. A logistic regression analysis (n = 179) confirmed that the time allotted per appointment was a significant predictor of the agreement time of optometrists as a barrier (χ2 [1] = 13.52, p < 0.001). Multiple linear regression showed that optometrists with less experience, charging lower fees, and working in large multiples or franchised practices have the shortest appointment times. CONCLUSION: The strong link found between postgraduate education and the confidence of optometrists in detecting glaucoma indicates that optometrists wishing to increase their scope of practice in the new legislative environment in Ireland may more actively seek training in areas of interest. The responses also indicate a lack of funding for the level of diagnostic testing required for accurate glaucoma diagnosis. Recent increases in the state's eye examination fees look likely to address the identified time and financial barriers to glaucoma detection in Ireland. Future work should look to analyse the effects of increased funding on optometric case finding for glaucoma.