Therapeutic endorsement enhances compliance with national glaucoma guidelines in Australian and New Zealand optometrists.

PURPOSE: Previous studies confirmed that optometrists have access to and confidence in applying clinical tests recommended for glaucoma assessment. Less is known about factors best predicting compliance with national clinical guidelines and thus by inference, the provision of suitable care by primary care ophthalmic practitioners. We utilised the unique two-tiered profession (therapeutic and non-therapeutic scope of practice) in Australia and New Zealand to assess the prospective adherence to glaucoma guidelines dependent on the clinician's background. METHODS: Australian and New Zealand optometrists were surveyed on ophthalmic techniques for glaucoma assessment, criteria for the evaluation of the optic nerve head, glaucoma risk categories and review times while also recording background, training, and experience. Parameters identifying progression/conversion and patients' risk levels were analysed comparatively to ophthalmologists' opinions. Linear regression analysis identified variables significantly improving the likelihood of concordance with guidelines. RESULTS: Reported application of techniques complied well with glaucoma guidelines although gonioscopy and pachymetry, pupil dilation for optic nerve head examination, and acquisition of permanent records were less frequently employed. The main predictors for entry-level diagnostic standards were therapeutic endorsement together with the associated knowledge of relevant guidance and procedural confidence. Other findings suggested a potential underestimation in the value of optic disc size and intraocular pressure for the prediction of glaucoma risk, while optometrists more frequently relied on the outcomes of non-standardised automated perimetry and auxiliary imaging. CONCLUSIONS: Optometrists in Australia and New Zealand may not always exercise optimal clinical acumen regarding techniques/criteria for glaucoma diagnosis. Therapeutic endorsement was gradually adopted in different jurisdictions in various forms since 1999 and is mandatory for registration since late 2014. The result of the two-tiered optometric cohorts suggest that inclusion of therapeutic training as part of the core training is likely a key factor to enhanced compliance with glaucoma guidelines. Improved adherence to the current clinical standards should positively impact on the facilitation of appropriate glaucoma diagnosis and management. Obligatory knowledge and possibly accreditation of available guidelines might ensure a uniform standard in glaucoma testing protocols in concordance with compulsory entry-level skills.

Clinical model assisting with the collaborative care of glaucoma patients and suspects.

BACKGROUND: Optimizing patient management will reduce unnecessary vision loss in glaucoma through early detection. One method is the introduction of collaborative care schemes between optometrists and ophthalmologists. DESIGN: We conducted a retrospective study to evaluate the impact of the Centre for Eye Health (CFEH) on glaucoma patient outcomes and management in primary optometric care. PARTICIPANTS: Patients referred to CFEH by optometrists for a glaucoma assessment were eligible for this study if written consent was provided (500 participants were randomly chosen). METHODS: Clinical data were classified according to disease risk and implemented patient care and analysed against the original diagnosis and patient parameters, followed by statistical analysis. MAIN OUTCOME MEASURES: Two main parameters were evaluated; suitable referral of patients for glaucoma condition assessment and appropriate implementation of follow-up care. RESULTS: The majority of patients referred for glaucoma assessment (86.2%) were classified as glaucoma suspects or likely to have glaucoma, indicating suitable referral of patients for a CFEH evaluation. Further, the involvement of CFEH resulted in a false positive rate of 7.8% for those patients who proceeded to ophthalmological care. However, long-term optometric patient care was not maintained for up to a third of primarily lower risk patients. CONCLUSIONS: The investigated collaborative eye health-care model led to a substantial improvement in appropriate referrals of glaucoma patients to ophthalmologists and could be suitable for optimizing patient care and utilization of resources. Improvement in follow-up of patients by optometrists is required to minimize inappropriately discontinued patient care.

Application of clinical techniques relevant for glaucoma assessment by optometrists: concordance with guidelines.

PURPOSE: Guidelines for the screening, prognosis, diagnosis, management and prevention of glaucoma were released by the Australian National Health and Medical Research Council in 2010. Comparable guidance has been made available by respective bodies in the USA and UK at a similar time. Key to successful translation of guidelines into clinical practice includes clinicians having the necessary skills to perform required tests. Optometrists in Australia and New Zealand were invited to participate in an online survey exploring these aspects. The results provide insights for improving glaucoma diagnosis and management by optometric primary eye care practitioners. METHODS: An online questionnaire was developed to investigate glaucoma assessment of optometrists as a function of demographic details, educational background and experience. Key points to ascertain compliance with current guidelines were the availability of equipment, procedural confidence in techniques, and preferences in visual field tests. Chi square statistics was employed to support similarity to national averages and highlight differences between the two countries. Multivariate linear regression analysis identified variables significantly associated with individual tests being available to optometrists and their confidence in applying them. RESULTS: Thirteen per cent of all Australian and 36% of the New Zealand optometrists responded to the survey in 2013, which reflected the demographics/geography of the practising populations. Techniques considered essential or preferred for glaucoma assessment were widely available in both countries with the exception of gonioscopy and pachymetry. After correcting for availability, regression models highlighted therapeutic endorsement and knowledge of glaucoma guidelines as the main variables to maintain high diagnostic confidence. Correlations to number of years in optometric practice mirrored a changed emphasis in teaching and technology over the past 10-15 years. CONCLUSIONS: Australian and New Zealand optometrists were well equipped to perform glaucoma assessments with the possible exception of gonioscopy. Advanced imaging modalities were not yet fully integrated into optometric practice, although optical coherence tomography has shown use by 23-32% of optometrists. A marked increase in use, availability and procedural confidence of gonioscopy and other techniques with therapeutically endorsed optometrists demonstrates the advantage and importance of additional training.

Validation of the Arabic version of the quality of life impact of refractive correction questionnaire.

PURPOSE: To validate the Arabic version of the quality of life impact of refractive correction (QIRC) questionnaire. METHODS: This was a cross-sectional study included participants with refractive errors (myopia, hypermetropia, or astigmatism) aged between 19 and 40 years who were pre or postrefractive surgeries. Uncorrected distance visual acuity, refraction, and corneal topography were collected. The 20-item QIRC questionnaire was translated to the Arabic language and then back translated to the English language. Participants were asked to answer all items of the Arabic QIRC. The validity and reliability of the translated questionnaire were tested using Rasch analysis. RESULTS: A total of 145 participants with refractive errors participated in this study. The mean age ± standard deviation of participants was 26.29 ± 5.1 years. Person separation (2.01) and reliability (0.80) indicates good precision and stability of the Arabic QIRC questionnaire. Item infit was ranged between 0.82 and 1.23; and item outfit was range between 0.76 and 1.32. The items were well targeted to the persons with a mean difference of 0.30. Skew and kurtosis values were within the normal limits (-2.00 to + 2.00). Cronbach's α for the scale was 0.79, which indicates good reliability of the Arabic 20-item QIRC. CONCLUSION: The Arabic 20-item QIRC questionnaire is a valid tool to assess the impact of refractive correction on Arabian participants' quality of life.

Association of Vitamin D deficiency with primary glaucoma among Saudi population - A pilot study.

PURPOSE: Glaucoma is a complex multifactorial disorder that is influenced by various systemic conditions. Several studies investigated the association between systemic factors such as Vitamin D deficiency for glaucoma development and reported contradicted findings. The aim of this study was to assess Vitamin D levels in glaucomatous Saudi subjects and its association with cup/disc ratio in primary open- and closed-angle glaucoma. METHODS: This was a pilot study that included subjects aged 41-78 years from both genders recruited from a tertiary hospital, Riyadh city, Kingdom of Saudi Arabia. Subjects were divided into three groups: Group 1: subjects with primary open-angle glaucoma (POAG), Group 2: subjects with primary angle-closure glaucoma (PACG), and Group 3: control subjects. All participants underwent detailed ophthalmic examinations including visual acuity, intraocular pressure measurement (IOP), gonioscopy, and fundus examinations. In addition, blood samples were collected from glaucoma patients and controls to measure the serum 25-hydroxyvitamin D levels. RESULTS: A total of 75 subjects were included in this study. Measurement of IOP was within the range of 9-27 for all subjects. Mean serum 25-hydroxyvitamin D levels were 72.58 ± 31.79, 69.20 ± 24.24, and 67.14 ± 29.02 in Groups 1, 2, and 3, respectively. There were insignificant differences in Vitamin D levels among the three groups (P > 0.05). Moreover, no significant correlation was noted between Vitamin D levels and cup/disc ratio in Groups 1 and 2. CONCLUSION: No association was found between Vitamin D deficiency and both POAG and PACG among Saudi population despite low serum level of Vitamin D in glaucomatous and control subjects. This study suggested that Vitamin D level may not contribute in augmenting the severity and progression of glaucoma.

Australian optometric and ophthalmologic referral pathways for people with age-related macular degeneration, diabetic retinopathy and glaucoma.

BACKGROUND: This study investigated the referral pathways offered to patients with age-related macular degeneration (AMD), diabetic retinopathy (DR) or glaucoma (GL) by ophthalmologists and optometrists. METHODS: Australian ophthalmologists and optometrists were surveyed regarding referral decisions to other eye-care specialists (inter- or intra-professional), general medical practitioners (GPs), low vision rehabilitation (LVR) and support services. Thematic analysis and concept mapping were applied to highlight current and ideal referral pathways. RESULTS: The survey was completed by 155 optometrists and 50 ophthalmologists and deemed representative of their respective professions in Australia. Not surprisingly, the vast majority of the participating optometrists (97 to 99 per cent) referred to ophthalmologists regardless of the underlying condition. Clear differences (Chi-square: p < 0.05) were observed in the referral patterns of optometrists and ophthalmologists to GPs and support services. General medical practitioner services were almost exclusively used for patients with DR, while AMD triggered a significantly higher referral rate to low vision rehabilitation and support services than the other two disorders. CONCLUSION: While ophthalmologists predominantly referred patients with AMD, DR or GL to low vision rehabilitation services, optometrists' referrals were highly skewed toward ophthalmology. Referrals to other supporting services by the two groups were not greatly used. The perceived referral pathways by the two eye-care professionals suggested a unidirectional route, potentially highlighting the need for a more collaborative approach that facilitates optimal use of eye health care and allied services.

Australian general medical practitioner referral pathways for people with different ocular conditions.

BACKGROUND: The aim was to obtain an overview of general medical practitioner (GP) referral pathways to ocular health care and allied services for people identified with age-related macular degeneration (AMD), diabetic retinopathy (DR) or glaucoma (GL). METHODS: A questionnaire was developed to survey GPs in Australia. Questions included demographic information and referral patterns to ocular and health service providers. The survey was posted to 1,050 randomly selected GPs across Australia. RESULTS: Fifty-eight GPs participated in this study amounting to a 6.5 per cent response rate. Nearly all GPs referred patients to ophthalmologists (AMD: 98 per cent; DR: 98 per cent; GL: 95 per cent). A smaller proportion of GPs also referred to low vision rehabilitation (LVR) services (AMD: 34 per cent; DR: 33 per cent; GL: 22 per cent), optometrists (AMD: 26 per cent; DR: 34 per cent; GL: 31 per cent), or support services (AMD: 17 per cent; DR: 40 per cent; GL: 19 per cent). For the three tested conditions, there were no statistically significant differences in the proportions of GPs, who referred to ophthalmologists (p = 0.43), optometrists (p = 0.48) or to low vision rehabilitation services (p = 0.31). The proportion of GPs who referred to support services was significantly higher for patients diagnosed with DR than AMD or GL (p < 0.05). CONCLUSION: The majority of GPs referred patients with AMD, DR or GL to ophthalmologists. Fewer GPs considered referrals to optometrists, low vision rehabilitation or support services. General practitioners may need to be more aware about the central role of optometrists in the delivery of primary eye health care. In the interest of optimising eye care, closer working relationships between GPs and optometrists should be fostered.