Glaucoma Comanagement: Optometrist-Ophthalmologist Model Shows Promise | Healio

A collaborative care model at the University of California San Francisco (UCSF) is showing promising results in glaucoma management, potentially expanding access to care and optimizing resource utilize. The program, detailed in a recent publication in Ophthalmology Glaucoma, involves glaucoma-trained optometrists working in tandem with ophthalmologists, allowing for stable glaucoma patients to be managed effectively by optometrists while ensuring specialist access remains available when needed. This approach could be particularly valuable in areas where access to glaucoma specialists is limited.

Training and Implementation at UCSF

The UCSF program centers around a structured training curriculum for optometrists. Participating optometrists completed didactic instruction, a minimum of three weeks of shadowing glaucoma specialists, and a supervised trial phase with direct oversight. This rigorous training ensures optometrists are well-equipped to manage stable glaucoma cases. The system currently involves four glaucoma specialists and three optometrists.

Patients diagnosed with glaucoma suspicion or stable glaucoma were offered two care pathways: either exclusive care from an optometrist until their condition required specialist intervention (“transfer care”), or alternating visits between an optometrist and an ophthalmologist (“alternate care”). Crucially, optometrists were instructed to refer patients back to an ophthalmologist if they observed elevated intraocular pressure (IOP) or any other signs of disease progression.

Study Findings: Glaucoma Stability Across Care Models

Researchers analyzed data from 775 eyes of 391 patients, with approximately 35% choosing the alternate care pathway. The primary outcome measured was glaucoma stability over a five-year period, assessed through several key clinical parameters: best-corrected visual acuity, IOP, average deviation on Humphrey visual field testing, and average retinal nerve fiber layer thickness measured via optical coherence tomography (OCT).

The analysis revealed no significant differences in these clinical parameters or medication usage between the two care groups over the five-year study period. Approximately 17% of eyes required treatment escalation, encompassing increased medication dosage (10.5%), glaucoma-related laser treatment (4.4%), and incisional surgery (2.2%). Importantly, the choice of care pathway – transfer or alternate – was not significantly associated with the need for escalation.

A more detailed analysis identified several factors associated with increased risk of treatment escalation. Older patients (P = .02), those with higher baseline IOP (P = .01), and individuals diagnosed with primary open-angle glaucoma (POAG) rather than glaucoma suspicion (P < .001) were all more likely to require more intensive treatment.

Patients in the “alternate care” group saw both optometrists and ophthalmologists roughly once per year, while those in the “transfer care” group saw optometrists twice per year and did not observe an ophthalmologist. This highlights the differing levels of specialist involvement in each pathway.

Implications for Glaucoma Care and Access

The UCSF comanagement model demonstrates the potential for appropriately trained optometrists to play a significant role in glaucoma care. As the study authors note, the majority of glaucoma patients have stable, mild disease and are currently managed by optometrists in real-world settings. Collaborative care, where optometrists and ophthalmologists work together, is gaining traction as a way to improve patient outcomes.

This model offers a potential solution to optimize resource utilization and improve patient access, particularly in areas where glaucoma specialists are scarce. By delegating stable cases to qualified optometrists, ophthalmologists can focus their expertise on patients with more advanced or rapidly progressing disease, ensuring timely and specialized care for those who need it most.

Understanding Glaucoma and the Importance of Monitoring

Glaucoma is a group of eye diseases that damage the optic nerve, often leading to vision loss and blindness. It’s frequently, but not always, associated with increased pressure inside the eye (IOP). Early detection and consistent monitoring are crucial for managing glaucoma and slowing its progression. Regular eye exams, including measurements of IOP, visual field testing, and OCT scans, are essential for individuals at risk.

It’s vital to understand that glaucoma often has no noticeable symptoms in its early stages. This represents why regular check-ups are so vital, especially for those with risk factors such as family history of glaucoma, African or Hispanic ancestry, diabetes, or high myopia (nearsightedness).

The Role of Intraocular Pressure (IOP) in Glaucoma Management

Intraocular pressure (IOP) is a key factor in glaucoma management, but it’s not the only one. Lowering IOP is a primary goal of treatment, as it can help unhurried the progression of optic nerve damage. Treatment options include eye drops, laser procedures, and surgery. However, even with normal IOP, some individuals may still experience glaucoma progression, highlighting the complexity of the disease.

What Comes Next: Expanding Comanagement Models and Further Research

The success of the UCSF program suggests that similar comanagement models could be implemented in other healthcare settings. Further research is needed to evaluate the long-term effectiveness of these models, identify best practices for optometrist training, and assess the impact on patient outcomes and healthcare costs. Ongoing surveillance and data collection will be crucial to refine these approaches and ensure optimal glaucoma care for all patients. The study authors suggest that continued evaluation of these models will help to define the optimal role of optometrists in glaucoma management and improve access to care for a wider population.

For more information on glaucoma, consult resources from the National Eye Institute or the Glaucoma Research Foundation. Individuals concerned about their risk of glaucoma should consult with a qualified eye care professional.