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Catriona Barrett, Colm J O'Brien, James Loughman; An Analysis of Optometry Referrals to Ophthalmology for Glaucoma Suspects. Invest. Ophthalmol. Vis. Sci. 2014;55(13):5567.
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The glaucoma care pathway in Ireland comprises an optometrist-led glaucoma screening service, with referrals channeled into ophthalmology services. Recent findings indicate a 31% false positive referral rate for suspect glaucoma, a factor that exacerbates the problem of escalating waiting lists in an under-resourced public health system. This study was designed to assess the quality of glaucoma referrals from optometry as a means to understand current practice in the context of a critical need to enhance the public health optometry role.
This study involved an analysis of glaucoma referrals from all 59 optometrists participating in a joint optometry/ophthalmology glaucoma referral refinement scheme at the National Optometry Centre, Dublin. Each of the 181 referrals included was assessed in terms of the (i) screening techniques used, (ii) clinical findings provided and (iii) comparison with clinical findings in the glaucoma clinic.
Non-contact tonometry (NCT) emerged as the primary clinical finding reported in the majority of referrals (98%), compared to optic disc description (87%), visual field assessment (70%), risk factor profile (62%) and cup-disc ratio (61%). Only 39% of referrals contained a copy of the visual field plot, while a disc height measurement was only provided in one referral (the method of disc assessment was typically not provided). Only 5% of intraocular pressure (IOP) measures were taken using Goldmann tonometry (GAT), and corneal thickness (CCT) measures reported in 3 cases. A statistically significant difference was observed between NCT values reported by the optometrists and both the raw GAT (mean difference = 0.99; p = 0.002, Bland Altman limits of agreement of ± 8.18mmHg), and CCT corrected GAT (mean difference = 2.39; p = 0.000, Bland Altman limits of agreement of 11.47mmHg) obtained in the glaucoma clinic. Cup-disc ratio measures reported in the referrals were not significantly different from those recorded in the clinic (mean difference ± SD = 0.01 ± 0.11; p = 0.393), although Bland Altman limits of agreement of ± 0.22 were observed.
Glaucoma referrals show a pattern of reliance on NCT and isolated CD ratios, which provide measures that are outside clinically acceptable limits of agreement with gold standard techniques. To improve the accuracy of glaucoma referrals, optometrists should adopt the use of GAT, CCT, disc measurement and dilated examination.
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