Glaucoma Comanagement: Optometrist-Ophthalmologist Model Shows Promise

UCSF Glaucoma Comanagement Program Shows Promise for Expanding Access to Care

A new comanagement program at the University of California, San Francisco (UCSF), is demonstrating a viable model for expanding glaucoma care, particularly in settings where access to ophthalmologists is limited. The program, detailed in a recent study published in Ophthalmology Glaucoma, involves training optometrists to manage stable glaucoma cases under the guidance of specialist ophthalmologists. This approach allows for efficient resource allocation and potentially improves patient access to essential eye care.

Glaucoma, a leading cause of irreversible blindness worldwide, often requires ongoing monitoring and management. While many patients have stable disease that could be effectively managed by optometrists, traditional care models often rely heavily on specialist ophthalmologists. This can create bottlenecks and limit timely access for those who need it most. The UCSF program addresses this challenge by equipping optometrists with the necessary skills and protocols to provide comprehensive glaucoma care, while maintaining a clear pathway for referral to specialists when needed.

The study analyzed outcomes from a comanagement model at UCSF involving glaucoma-trained optometrists and fellowship-trained ophthalmologists. Participating optometrists completed a structured curriculum that included didactic instruction, a minimum three-week shadowing period with glaucoma specialists, and a supervised trial phase. This rigorous training ensures optometrists are well-prepared to identify and manage stable glaucoma cases, and to recognize signs of progression requiring specialist intervention.

Researchers followed 775 eyes from 391 patients, offering them two care pathways: either exclusive care from an optometrist until their condition warranted escalation (“transfer care”), or alternating visits between an optometrist and an ophthalmologist (“alternate care”). In both scenarios, optometrists were instructed to refer patients back to an ophthalmologist if they observed elevated intraocular pressure (IOP) or other indicators of disease progression. The primary outcome measured was glaucoma stability over a five-year period, assessed through metrics like visual acuity, IOP, visual field testing, and optical coherence tomography (OCT) imaging of the optic nerve.

No Significant Differences in Glaucoma Stability

The analysis revealed no significant differences in clinical parameters or medication usage between the two groups over the five-year study period. Treatment escalation – meaning increased medication, laser treatment, or incisional surgery – was required in 17% of eyes overall. Importantly, the care pathway (transfer vs. Alternate) was not significantly associated with the likelihood of needing escalation.

A more detailed analysis identified factors associated with treatment escalation. Older patients, those with higher baseline IOP, and individuals with primary open-angle glaucoma (the most common form of the disease) were all more likely to require more intensive treatment. These findings align with established risk factors for glaucoma progression and underscore the importance of careful patient selection and monitoring.

Patients in the “alternate care” group saw both optometrists and ophthalmologists approximately once per year, while those in the “transfer care” group saw optometrists twice per year and did not see an ophthalmologist. This highlights the potential for optometrists to effectively manage stable glaucoma cases, reducing the burden on specialist ophthalmologists.

Optimizing Resource Utilization and Expanding Access

The UCSF model demonstrates the potential for a collaborative approach to glaucoma care, where appropriately trained optometrists play a central role in managing stable disease while maintaining close collaboration with glaucoma specialists. This model could be particularly valuable in areas with limited access to ophthalmologists, such as rural communities or underserved populations. By delegating stable cases to optometrists, specialists can focus their expertise on patients with more complex or rapidly progressing disease.

“This model has the potential to optimize resource utilization and improve patient access, particularly in settings where glaucoma specialist access is limited,” the study authors wrote. “By allocating stable glaucoma patients to appropriately trained optometrists, glaucoma specialists can focus on patients with advancing disease who require timely, high-level specialized care.”

The success of the UCSF program hinges on the quality of training provided to optometrists. The structured curriculum, including shadowing and supervised practice, is crucial for ensuring optometrists are competent in medical glaucoma management. Ongoing professional development and continuing education are also essential to maintain expertise and stay abreast of the latest advancements in glaucoma care. Artificial intelligence models are also showing promise in predicting glaucoma progression, potentially aiding in risk stratification and treatment decisions.

What’s Next for Glaucoma Comanagement?

The findings from UCSF support the growing trend toward collaborative care in glaucoma management. Further research is needed to evaluate the long-term outcomes of comanagement models and to identify best practices for implementation in diverse healthcare settings.

Ongoing studies are exploring the role of telemedicine and remote monitoring in glaucoma care, which could further expand access and improve patient convenience. Collaborative care models are also being investigated for their impact on patient satisfaction and quality of life. The American Academy of Ophthalmology and other professional organizations are developing guidelines and resources to support the implementation of effective comanagement programs.

the goal is to create a sustainable and equitable system of glaucoma care that ensures all patients have access to timely and appropriate treatment, regardless of their location or socioeconomic status. More information about Marfan syndrome can be found on Healio.