An audit on the impact of training for a Referral Refinement Scheme in Northern Ireland on community optometrists’ clinical practice when assessing for signs of glaucoma

AuthorsShelley Black*, Julie McClelland and Patrick Richardson

Optometry and Vision Science Research Group, School of Biomedical Sciences,

Ulster University, Coleraine, BT52 1SA, Northern Ireland, United Kingdom

AcknowledgementsThe authors wish to acknowledge the College of Optometrists for funding, Dr Sayeed

Haque for statistical support given to the project and the four community practices

and optometrists who participated in the audit.

Introduction Glaucoma services in Northern Ireland and other parts of the United Kingdom came

under significant pressure as the number of ocular hypertensive referrals to the

service increased in recent years (Shah et al. 2011; Ratnarajan et al. 2013). This

was a result of the implementation of NICE Clinical Guideline 85 (NICE 2009) in

2009 coupled with a recommendation from the Association of Optometrists that all

patients presenting with repeatable intraocular pressures (IOPs) of more than

21mmHg should be referred to an ophthalmologist regardless of the type of

tonometer used to make the measurement (AOP 2010).

Northern Ireland’s Health and Social Care Board engaged with the Belfast Local

Commissioning Group and other key stakeholders to commission a redesign of

glaucoma services with the aim of refining glaucoma referrals and reducing the false

positive referrals which were flooding the hospital eye service (HES).

The first glaucoma Local Enhanced Service (LES) began in December 2013 as a

repeat measure scheme to reduce false positive ocular hypertension referrals. To

partake in the scheme, primary care optometrists required training and accreditation

from Ulster University. Optometrists were issued with a distance learning package

consisting of video lectures in

1 Contact tonometry

2 Slit lamp binocular indirect ophthalmoscopy

Black et al OiP Submission 2017 1

3 Optic disc analysis

4 Anterior chamber assessment

The training package reviewed the importance of these four areas when assessing

for clinical signs of glaucoma. A summary of the training has been detailed below.

High IOPs

Patient’s presenting with high IOP are more at risk of glaucoma , however it is should

be noted that about 40% of patients with glaucoma have IOP within the normal range

(Shah et al. 2011). It is important for optometrists investigate other clinical signs

before deciding whether to refer the patient as a glaucoma suspect or ocular

hypertensive. The College of Optometrists advise that it is good practice to follow up

equivocal results from non-contact tonometry (NCT) with contact applanation

tonometry (CT) (CoO 2017).

Glaucomatous disc features

Binocular indirect ophthalmoscopy is the recommended method to examine the optic

disc as it enables a more accurate, less variable estimation of the optic cup to disc

size than direct ophthalmoscopy. Direct ophthalmoscopy tends to underestimate cup

to disc ratio (Watkins et al. 2003).

Jonas et al performed a major review of ophthalmoscopic evaluation of the optic

nerve head (Jonas et al. 1999). In order to detect early glaucomatous optic disc

damage in ocular hypertensive eyes before visual field loss occurs, the authors

recommend that the following features of the optic disc are assessed:

Shape of the neuroretinal rim (NNR)

Optic cup size in relation to the size of the optic disc

Quality of the retinal nerve fiber layer (RNFL)

Presence of disc hemorrhages

Shape of the neuroretinal rim (NRR)

In normal eyes, classically the perceived thickness of the NRR has a characteristic

pattern, based on the vertically oval shape of the disc and the horizontally oval

shape of the cup. The NRR is normally broadest inferiorly, then superiorly, then

nasally with the temporal region the narrowest, which lead to the development of the

“ISNT rule” (Harizman et al. 2006; Jonas et al. 1999).

Black et al OiP Submission 2017 2

It is important in the detection of glaucomateous disc damage to observe the location

and extent of any NRR loss as this can be indicative of the stage of the disease

progression (Hammel et al. 2016). Figure 1 shows NRR loss progression in a

glaucomatous disc. These changes correlate with the progression and location of

visual field defects with early glaucoma (Jonas et al. 1999).

Figure 1

Optic cup size in relation to the size of the Optic Disc

In normal eyes the size of the optic disc and optic cup should correlate with each

other; the bigger the disc, the bigger the cup (Jonas et al. 1988). A small disc with a

large cup or asymmetry between the cup to disc ratio would be suggestive of

glaucoma, particularly if the configuration of the NRR does not agree with the ISNT

rule (Jonas et al. 1999).

Quality of the RNFL

Black et al OiP Submission 2017 3

Glaucomatous optic nerve atrophy is associated with optic nerve fibre loss,

decreasing the visibility of the RNFL either diffusely or with localised defects (Jonas

et al. 1999; Jonas et al. 1994; Kubena et al. 2011). The RNFL can be viewed

through a red- free filter in direct or indirect binocular ophthalmoscopy or through a

red-free filter in fundus photographs. A wedge-shaped RNFL inferior defect is shown

in Figure 2 (Thomas R, 2006).

Figure 2

Presence of Disc Hemorrhages

A hallmark of optic disc atrophy is flame-shape hemorrhages at the edge of the optic

disc. Disc hemorrhages are rarely observed in non-glaucomatous eyes (1%) (Healey

et al. 1998; Klein et al. 1992) so normally indicate the presence of optic disc damage

(Jonas et al. 1999). Disc hemorrhages are often associated with localised RNFL

defects (figure 2), NRR notches and visual field loss (Jonas et al. 1994)

Anterior Chamber Angle (ACA)

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The closure or blockage of the anterior chamber angle can lead to acute angle

closure glaucoma (ACG). There are certain ocular characteristics which predispose

the eye to ACG (Congdon et al. 1996; Dabasia et al. 2013; Lowe 1970);

i. Shallow ACA depth

ii. Anterior lens positioning

iii. Thickening of the lens

iv. Small corneal diameter

Nolan et al. (2006) highlighted shallow ACA as the prime risk factor for developing

ACG.

Pigment dispersion syndrome and pseudoexfoliation syndrome can result in

secondary glaucoma as a result of the trabecular meshwork becoming blocked

reducing aqueous drainage, raising IOP and damaging the optic nerve.

In community optometric practice, few practitioners have access to a gonioscope or

have training in gonioscopy (Jamous et al 2014; Lockwood et al. 2010; Myint et al

2010) which is the gold-standard method of assessing the anterior chamber.

However, where gonioscopy is not possible, Van Herick test is an acceptable

alternative in grading the anterior chamber angle depth (Dabasia et al. 2015). An

angle measured by Van Herick technique to be grade 2 or less should be referred to

secondary services for further investigation (CoO 2016; HIS 2015).

LES AccreditationLES accreditation was granted once practitioners successfully completed a multiple

choice written examination and practical assessment of contact tonometry, optic disc

analysis using slit lamp binocular indirect ophthalmoscopy and measuring the

anterior chamber angle using Van Herick technique. In August 2014 more than 250

optometrists in Northern Ireland had received accreditation, this has now risen to

over 350.

Accredited optometrists were to use the new referral refinement scheme pathway

when a patient presented with IOPs over 21mmHg. This pathway has been

summarised in Figure 3.

Black et al OiP Submission 2017 5

Figure 3

Many Health Boards across the UK have also introduced glaucoma referral

refinement schemes (Devarajan et al. 2011; Keenan et al. 2015; Ratnarajan et al.

2015; Trikha et al. 2012). The majority of these schemes have been evaluated by

auditing the quality and outcomes of the referrals received by the HES (Devarajan et

al. 2011; Ratnarajan et al. 2015; Trikha et al. 2012). There is limited data in the

literature demonstrating the views of providers as part of scheme evaluation (Baker

et al. 2016). Moreover, none have examined the impact of the additional training on

the day-to-day clinical practice of accredited optometrists.

The purpose of this audit was to explore whether LES accreditation impacted on

optometrists practice habits when assessing for signs of glaucoma following referral

refinement training.

Methods

The audit comprised three stages; in stage one the author, a glaucoma accredited

optometrist, examined the patient records of optometrists before and after they

received LES training, in stage two audited optometrists were surveyed on how they

Black et al OiP Submission 2017 6

felt the training impacted their routine clinical practice and in stage three the survey

was extended to all LES accredited optometrists in Northern Ireland.

Ulster University’s ethics filter committee and NHS ethics committee categorised this

study as an audit.

Stage 1Data from electronic patient records were collected from four community optometry

practices in Northern Ireland. Patient records were reviewed from a period before the

LES training took place (January 2013 to February 2013) and compared to a period

after the LES training (July 2014 to August 2014).

The inclusion criteria for the audit were records from patients who were over 40

years old and had a first degree family history of glaucoma (FHG). Age matched

records of patients without a FHG were included as controls. Patient records where

individuals had a diagnosis of glaucoma were excluded.

Records were reviewed for information on: intraocular pressure (IOP), optic disc

(OD) description, examination techniques used in ocular assessment, visual fields

and referral.

N.B. If an optometrist recorded a technique or description in 95% or more of their

audited patient records this was noted as ‘always’, 50% to 94% was noted as

‘usually’, 5% to 49% was noted as ‘sometimes’ and 0% to 4% as ‘never’. This is to

aid comparison of stage 1 and stage 2’s results.

Stage 2 Each optometrist from the four community practices participating in the audit was

emailed a link to complete an online survey. The survey was designed to elicit

information on the clinician’s practice with regards to how they assessed patients for

signs of glaucoma before and after they had LES training.

The survey comprised of eight closed questions, six of which required a four-point

scale response ranging from ‘never’ to ‘always’ and a final free response question

(Figure 4).

Black et al OiP Submission 2017 7

Figure 4

Stage 3Ulster University possess a list of all the optometrists who received accreditation

through their LES training programme. The optometrists were emailed an invitation

to complete the survey online. The survey consisted of the same questions used in

stage 2 (Figure 2) but with the additional free response question, ‘If you do not

always use a contact tonometer to repeat IOP measurement since becoming

accredited, please comment why’.

Results

Stage 1- Record AnalysisThe database of 13,031 records produced 1,138 records which met the inclusion

criteria; 604 pre-LES training, 534 post-LES training. Data from 17 optometrists

working in the four practices were included in the audit.

Comparison of individual optometrist’s records pre and post LES training

Twelve of the seventeen optometrists had a minimum number of forty records, 20

with a FHG and 20 without a FHG, which could be analysed pre and post LES

training. The analysis focused on three main areas of practice:

Black et al OiP Submission 2017 8

1. The method chosen for ocular examination on patients with and without a

FHG

2. The optic disc assessment in patients with a FHG

3. The assessment of the anterior chamber angle (ACA) in patients with a FHG

Instances in which initial IOP was over 21mmHg and where the patient was referred

along the referral refinement pathway were too few per optometrist to analyse

effectively. There was no access to visual field plots in two of the practices involved

in the audit. This was due to a change in filing system from paper to an electronic

database that was ongoing during the data collection period.

The results from Stage 1 have been summarised in Table 1. Comparison of the

individual optometrist’s record set from both pre and post LES training, highlights the

following key findings post training:

More of the optometrists are using indirect ophthalmoscopy to examine to

ocular health.

The optometrists increasingly record the quality of the optic disc’s

neuroretinal rim (NRR) in patients with a FHG.

The ACA in patients with a FHG is assessed by more optometrists the pre

training.

Black et al OiP Submission 2017 9

Table 1

Areas of Practice

Before LES Training %

(n)

After LES Training %

(n)

N=12 Optometrists

Method of Ocular Examination

Direct ophthalmoscopy used in ≥ 50% of the optometrist’s record set. (“Always/Usually”)

33% (4) 8% (1)

Indirect ophthalmoscopy used in ≥ 50% of the optometrist’s record set. (“Always/Usually”)

42% (5) 75% (9)

Method of ocular examination not recorded in the optometrist’s record set.

25% (3) 17% (2)

Recorded optic disc description in patients with a FHG

NRR recorded in <50% of the optometrist’s record set.(“Sometimes/Never”)

42% (5) 25% (3)

NRR recorded in ≥ 50% of the optometrist’s record set.(“Usually/Always”)

50% (6) 58% (7)

Optic disc compared to the ISNT rule in ≥95% of the optometrist’s record set. (“Always”)

8% (1) 17% (2)

Recorded assessment of the ACA in patients with a FHG

No assessment of ACA in the optometrist’s record set. (“Never”) 100% (12) 67% (8)ACA recorded in 5-49% of the optometrist’s record set.(“Sometimes”)

0% (0) 17% (2)

ACA recorded in 50-94% of the optometrist’s record set. (“Usually”)

0% (0) 17% (2)

Comparison of all records pre and post LES training

All 1138 records from the larger data set were analysed for statistical differences

between optic disc description, assessment of the ACA and the method chosen by

the optometrist for ocular examination pre and post LES training, Table 2.

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Table 2

Before LES Training % (n)N=604 records

After LES Training % (n)N=534 records

Indirect ophthalmoscopy used for ocular examination

56% (340) 67% (357)

Description of the optic disc’s NRR recorded

48% (290) 46% (246)

Assessment made of the ACA

0.2% (1) 5.2% (28)

No significant difference was found between the method chosen by the optometrist

to examine ocular health or in their description of the optic disc following training.

Statistical differences, however, were found using independent sample T test

between the number of records containing details of an ACA assessment pre and

post training. More records had an assessment of the ACA documented post training

(p=0.000, t[565]= -5.183), this was true for both patients with a FHG (p=0.000,

t[310]=-4.181) and those without a FHG (p=0.003, t[250] =-3.049).

Intra- Ocular Pressures (IOPs)

1,136 (99.8%) of the 1,138 patient records audited (with and without a FHG) had an

initial IOP measurement recorded, 43 (4%) of those had initial IOPs greater than

21mmHg, 32 pre LES training and 11 post LES training. In the pre LES records

where the IOPs were found to be over 21 mmHg, 11 (34%) had a repeat measure

made with a non-contact tonometer (NCT) and in 21 cases there was no repeat

measure made. Post LES training, 4 (36%) records had no repeat measure taken, 2

(18%) had a repeat measure recorded with a NCT and 5 (46%) had IOPs repeated

with a contact tonometer (CT).

Stage 2- Survey of audited optometrists All of the audited optometrists (n=12) completed the online survey. Tables 3,4 and 5

summarise the responses returned by the participants from questions 1 to 8 on how

they feel the additional training has impacted on specific areas of their daily practice.

Since receiving accreditation:

Black et al OiP Submission 2017 11

More practitioners report using indirect ophthalmoscopy when examining the

optic disc.

The number of optometrists assessing the anterior chamber in patients with a

FHG has increased.

More practitioners now use a contact tonometer to repeat IOPs if found

initially to be >21mmHg.

Little change was reported in what the practitioners record in their description

of the optic disc

Table 3

Never% (n)

Sometimes% (n)

Usually% (n)

Always% (n)

Before receiving LES training, did you use a volk lens and slit lamp to examine the optic disc?

0% (0) 33% (4) 0% (0) 67% (8)

After receiving LES training, do you use a volk lens and slit lamp to examine the optic disc?

0% (0) 17% (2) 0% (0) 83% (10)

Before receiving LES training, did you assess the depth of the patient’s anterior chamber of there was a FHG?

25% (3) 67% (8) 8% (1) 0% (0)

After receiving LES training, do you assess the depth of a patient’s anterior chamber if there’s a FHG?

0% (0) 25% (3) 50% (6) 25% (3)

Table 4

CD ratio only

% (n)

CD ratio and NRR

% (n)

CD ratio and ISNT

% (n)

CD ratio, NRR, cup

depth, ISNT% (n)

Before receiving LES training, what did you regularly record when describing the optic disc?

8% (1) 75% (9) 8% (1) 8% (1)

After receiving LES Training, what do you regularly record when describing the optic disc?

0 (0) 83% (10) 8% (1) 8% (1)

Table 5

Black et al OiP Submission 2017 12

NB. Respondent could select more than one option

Before LES training, did you repeat a patient’s IOPs if found to be >21mmHg?

% (n)

After LES Training, do you repeat a patient’s

IOPs if found to be >21mmHg?

% (n)Never 0% (0) 0% (0)

Sometimes with a NCT

17% (2) 8% (1)

Usually with a NCT 25% (3) 8% (1)

Usually with a CT 0% (0) 33% (4)

Always with a NCT 67% (8) 50% (6)

Always with a CT 0% (0) 42% (5)

In the final question clinicians were asked to comment on what impact, if any, they

felt the LES training had on their clinical assessment for signs of glaucoma. Seventy-

five percent (n=9) reported that LES training had improved aspects of their clinical

practice, 17% (n=2) reported very little impact and 8% (n=1) reported no

improvement. Seventeen percent (n=2) of the respondents noted that even with the

training they still did not feel confident in performing contact tonometry.

Stage 3- Survey of all LES accredited optometrists

ParticipantsOver 350 optometrists had received LES accreditation in Northern Ireland at the time

when the survey was launched. Valid email addresses were available for 341

accredited optometrists, 110 completed the survey representing a 32% participation

rate. Participants had the option at the end of the survey to provide details on the

following:

year of professional qualification

primary place of work

additional qualifications

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The information collected has been summarised in Table 6.

Table 6

No. of respondents (n)

Details

Qualifying year 70 51% 2000-200923% 1990-199911% 1980-19899% 2010-20156% 1970 -1979

Primary place of work(May be split between more than one sector)

69 55% Independent38% Multiple4% Locum4% University2% Hospital

Additional qualifications 32 38% Professional Certificate in Glaucoma22% None13% Professional Certificate in Medical Retina 9% Independent Prescribing6% Ocular Therapeutics6% Diploma in cataract and refractive surgery3% Diploma in School Vision 3% Diploma in Sport Vision 3% MPhil 3% MSc3% PhD

Survey Responses

Black et al OiP Submission 2017 14

Compulsory QuestionsBefore/after receiving   LES training, did/do you use a volk lens and slit lamp to

examine the optic disc?

Figure 5 shows the distribution of respondents’ use of a volk lens and slit lamp when

examining the optic disc before and after receiving LES training. The majority of

respondents reported that they “sometimes” used a volk lens to assess the optic disc

before receiving LES accreditation whereas after training, the majority reported

“always” using indirect ophthalmoscopy. This change, however, was not found to be

statistically significant.

A relatively moderate correlation was found between the year of qualification of the

optometrists and the use of a volk lens to examine the optic disc, with more recently

qualified optometrists likely to use a volk lens both before (rs=.403, p=0.001) and

after (rs=0.342, p=0.005) accreditation.

Black et al OiP Submission 2017

Before LES Training After LES Training

Figure 5

15

Before/after receiving LES training, did/do you assess the depth of a patient's

anterior chamber (ACA) if there was a family history of glaucoma?

Figure 6 displays the optometrists’ responses to the trainings’ impact on their

measurement of the ACA in patients with a FHG. More optometrists report

assessment of the ACA following training. The percentage of those “always”

measuring the ACA is 2.7 times greater following accreditation. This increase in

frequency in ACA assessment was found to be statistically significant (p=0.000,

Mann-Whitney U=3161).

Before/after receiving LES training, what did/do you regularly record   when

describing   the optic disc?

Figure 7 compares what practitioners would include on patient records when

documenting a description of the optic disc before and after LES training. Although

there is an increase in the percentage of practitioners that record a description of the

NRR and who refer to the ISNT rule when evaluating the optic disc, the difference

was not found to be statistically significant.

Black et al OiP Submission 2017

Before LES Training After LES Training

Figure 6

16

No description CD ratio CD ratio and NRR CD ratio and ISNT Other 0%

10%

20%

30%

40%

50%

60%

70%

0%

16%

58%

17%

8%

0%3%

60%

25%

13%

Before receiving LES training, what did you record in your description of the optic disc After receiving LES training, what do you record in your description of the optic disc

Figure 7

Before/after receiving LES training, did/do you repeat a patient's IOP readings if

found to be over 21mmHg?

Table 7 compares the responses of participants when asked if they repeat IOP

readings if found to be over 21 mmHg before and after accreditation. Respondents

could select multiple responses. The most notable change is the increase in the use

of the CT. Before the training 45% of practitioners stated that they would always

repeat IOP readings with a NCT and 19 % always with a CT if over 21mmHg. After

the training 77% reported always repeating the measurement with a CT and only 9%

always with a NCT. This shift in practitioner instrument choice was found to be

statistically significant (p=0.000; Mann-Whitney U=2691).

Black et al OiP Submission 2017 17

Table 7

IOP reading repeated if initially found to be >21mmHg

Before LES Training % (n)

N=110

After LES Training % (n)N=110

Never 1% (1) 0% (0)

Sometimes with a NCT 6% (7) 4% (4)

Sometimes with a CT 13% (14) 5% (6)

Usually with a NCT 23% (25) 3% (3)

Usually with a CT 9% (10) 14% (15)

Always with a NCT 45% (50) 9% (10)

Always with a CT 19% (21) 77% (85)

Other 2% (2) 3% (3)

Open optional questions

If you do not always use a contact tonometer to repeat IOP measurement since

becoming accredited, please comment why.

Nine participants commented on this section of the survey. Three would repeat IOPs

with a NCT first, if the results were in normal limits, they did not repeat again with a

CT. Two remarked that if there were other signs indicative of glaucoma they would

instead refer via the glaucoma referral pathway. Other reasons why respondents

would not always repeat IOP readings with a CT included; if the patient was already

attending the HES due to raised IOPs, if the practice they were working in was not

registered for the LES scheme and as a CT was the primary method of one

practitioner, they did not need to repeat the readings. One optometrist stated that

although they always repeat IOP measurement with a CT they do not always make a

claim to attain the LES fee as they find the process too difficult.

Black et al OiP Submission 2017 18

What   impact, if any, do you feel the LES training has had on your   clinical

assessment for the signs of glaucoma?

Eight- two participants completed this question, the answers were analysed using

the online survey’s text analysis function (Ten Kleij 2003) The majority noted a

positive impact in their clinical assessment for the signs of glaucoma, 19% reported

little or no improvement, Table 8.

Table 9 contains a range of the practitioners’ responses.

Table 8

Impact of LES training on clinical assessment for the signs of glaucoma

Percentage %(n)N=82

None 6% (5)

Little improvement 13% (11)

Reduced unnecessary referrals 5% (4)

Formalised Clinical assessment 1% (1)

Raised confidence 11% (9)

Improved clinical assessment 63% (52)

Black et al OiP Submission 2017 19

Table 9: The Impact of training on clinical practice

Black et al OiP Submission 2017

Stage 3- Statistically significant key findings

2.7x more optometrists assessed the ACA in patients with a FHG following LES accreditation.

More recently qualified optometrists are likely to use indirect ophthalmoscopy for ocular examination regardless of training.

More practitioners repeated initially raised IOPs with a contact tonometer following training. 20

Positive Impact ‘it has radically improved my understanding of Glaucoma detection’

‘LES training has improved both my competence and confidence in my clinical assessment for the signs of glaucoma’

‘Has made me assess the disc appearance more carefully and thoroughly, also I always do Van Herick now’

‘Better structure to my investigation and better quality information gathered’

‘More in depth tests before considering referral, less referrals made’

‘I feel more competent at repeating IOPs by a hospital approved method and more confident that I have selected the appropriate referral pathway if required’

‘I feel it has definitely minimised unnecessary referrals to glaucoma services in HES and has made my job feel more worthwhile clinically’

Very Little Impact ‘Very little although I can do goldmann and understand what I am looking for I don’t feel confident in my results as I do it so irregularly’

‘Other than rechecking pressures with contact tonometry not much’

‘I am better informed-but still less than fully competent. However, I still get next to no feedback- so how to improve?’

No Impact ‘I do the same now as before the training’

DiscussionThe current study combines the views of practitioners on the impact of the LES

training scheme along with information taken from patient records. It has been

shown in the literature that clinicians can at times ‘under-record’ the tests that they

carry out (Luck et al. 2000; Shah et al. 2007) and that in questionnaires practitioners

may state that they do more than they do in reality (Franco et al 1997; Shah et al.

2007). This combined approach permits a deeper insight into the ‘real’ effect of

enhanced training on the community optometrist’s routine practice.

Comparison of clinical record review and survey results

Results from Stage 1 and Stage 2 demonstrate that more practitioners use indirect

ophthalmoscopy to examine the optic disc post LES training although this increase

was not found to be statistically significant.

The outcomes from both methods show a significant increase in the assessment of

the ACA by practitioners in patients with a FHG, subsequent to training. In the survey

however, 75% of optometrists reported that they would “usually/always” assess the

ACA in patients with a FHG following accreditation whereas the review of clinical

records showed that only 17% regularly recorded an assessment of the ACA. It is

unclear if this is an example of under-recording or over-reporting in the survey.

IOP measurement

Before practitioners received LES training, contact tonometry was rarely used to

repeat the IOPs of a patient whose initial readings were over 21mmHg.

Results from clinical records and the survey issued in stage 2 and 3 show that the

use of the CT increased following training. There is evidence that some optometrists

still used a NCT alongside a CT to repeat IOP measurements. A lack of confidence

in their contact tonometry results reported by optometrists’ in the open question

section of the survey may account for this.

Trends

Recently qualified optometrists are more likely to use indirect ophthalmoscopy

compared with more experienced practitioners. This is possibly due to universities

Black et al OiP Submission 2017 21

like Ulster University encouraging students to use indirect ophthalmoscopy as part of

their routine ocular assessment.

Following training 2.7x more optometrists reported assessing the ACA. This may be

as a result of the training package with some optometrists stating that the training

made them do ‘more in depth tests before referral’ and ‘always do Van Herick now’.

Impact of the service

The majority of accredited optometrists surveyed felt the LES training had improved

their clinical assessment for signs indicative of glaucoma and some stated that the

training increased their confidence.

A report released in November 2015 from Northern Ireland’s Health and Social Care

Board (HSCB 2015) showed that since the introduction of the LES scheme, 65%

(n=2237) of patients who initially presented with IOPs >21mmHg were not referred

after referral refinement reducing the number of referrals and burden onto the HES.

The report also included an audit of referrals that had been sent to the Belfast Health

and Social Care Trust in a three week period during March 2015 via the referral

refinement scheme. The audit showed that there was still a significant percentage

(36%) of false positives.

The views of the optometrists from the current study agree with Konstantakopoulou

et al. (2014) in which all of optometrists working within a Glaucoma Referral

Refinement Scheme (GRRS) in Manchester felt that their glaucoma detection skills

had improved significantly, particularly in the recognition of false positive cases. The

need for more specific feedback from the hospital to improve future referrals was

brought to light by some of the surveyed Northern Ireland optometrists. This is

something that has also been identified in other studies (Konstantakopulou et al.

2014; Needle et al. 2008; Whittaker et al. 1999). GRRS optometrists in Manchester

did receive feedback from their referrals, reporting that they valued both the quality

and frequency of the feedback (Konstantakopoulou et al. 2014).

Northern Ireland’s Health and Social Care Board hopes to further reduce false

positives by the introduction of LES II for glaucoma (HSCB 2016). Practitioners

wishing to participate in LES II will be required to have the College of Optometrists

Professional Certificate in Glaucoma and attend training provided by the board on

LES II protocol. LES II practitioners will be expected to carry out the following clinical

tests on eligible patients:

Black et al OiP Submission 2017 22

i. IOP measurement via CT

ii. Anterior chamber assessment and estimate of angle width.

iii. Dilated optic nerve assessment with binocular indirect ophthalmoscopy

iv. Central threshold automated perimetry

Eligible patients include those with one or more of the following clinical signs:

i. Patients with IOPs above the normal range for their age when repeated with

applanation tonometry (LES I)

ii. A repeatable visual field defect/loss with normal IOP and normal optic disc

appearance.

iii. IOPs outside age- related range and a suspicious optic disc appearance with

normal visual fields

iv. Anterior segment signs of secondary glaucoma with IOPs outside age-related

range.

After the additional assessment the LES ll accredited optometrist has more clinical

freedom to continue to manage the patient within primary care in the absence of

definitive evidence of glaucoma.

Areas of further research

Once LES II has been introduced to Northern Ireland a similar audit should be

employed to assess the number of false positives referred to the HES and the impact

LES II has on not only the optometrists involved but all key stakeholders.

Conclusion

This study shows that optometrists report finding additional training beneficial to their

clinical practice can be successfully trained to reduce false positive ocular

hypertensive referrals.

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