1. Community Monitoring for Glaucoma
Katrina Venerus - Clinical Director, LOCSU
Dharmesh Patel – Commissioning Lead, LOCSU

2. Learning Objectives
1.2.4 Explain to patients the implications of their eye condition and the importance of adherence to the management plan set by the ophthalmologist before their referral to the community monitoring service
1.2.5 Communicate effectively with ophthalmologists and other clinicians involved in the care of patients with glaucoma
Work collaboratively with colleagues within other healthcare professions in the best interest of patients with glaucoma ensuring communication is clear and effective
Understand when referral to a consultant ophthalmologist is clinically justified and in the best interests of the patient

3. Glaucoma Predicted rise of glaucoma cases
22% in next 10 years (18% glaucoma suspects, 16% OHT)
44% in next 20 years
57% of consultants reported an existing backlog that is causing delays to the follow up patients; new patients are on a target driven pathway, so delays not tolerated.
Number of ophthalmologists expected to remain relatively steady so someone else is going to need to contribute to patient care, either within the HES or in the community.
Two thirds of the cost of glaucoma care is spent on clinical care rather than drugs.

7. Aims of Integrated Community Monitoring
Provision of timely care by appropriately trained and competent professionals.
Delivery of high quality clinical services ensuring patient safety and positive patient experience.
Reconfiguration of patient flows to make best use of available resources and skills mix.
Provision of education and training for the development of the future workforce.
Embedding of comprehensive governance structures.
Provision of services in a setting closer to home or work.

8. Consultant Led Glaucoma Clinic Diagnosis & Treatment
Low Risk
OHT/Suspect POAG(No Tx)
/Treated PACG
(ONH/VF Undamaged)
Medium Risk
OHT/Suspect PCOAG under Tx
Early to Moderate POAG – Apparently ‘Stable’ for >12mths
High Risk
Complex - inc COAG, PACG/ 2nd Glauc / Rare Glauc
Management Plan
[Including Re-referral criteria and frequency of review]
Transfer to Community Optometry to Virtual Clinic
Retain in Face to Face Glaucoma Clinic
Community Assessment VA
Supra-Threshold Visual Fields
IOP – Goldman
Slit Lamp Bio
Van Herick
(Retinal Photos desirable)
Virtual Clinic
Threshold Visual Fields
(Humphrey VFA or Henson 9000)
Retinal Photos
Recording Compliance with Tx
(RNFL/OCT analysis desirable)
No Change in Clinical Status
Change In clinical Status
Review as per Management Plan
(Typically 12mths)
Or Discharge as per NICE
Refer back to glaucoma clinic for review
Virtual Review by delegated glaucoma reviewer
Review in community as per management plan
Appointment for F2F review in glaucoma clinic
Risk Stratification*
Discharge to Community Optometry for Monitoring

9. Integrated Glaucoma Monitoring Service
How will it work?
Risk stratification exercise
consultant ophthalmologists and specialist optometrists will rank patients as having high/medium/low risk of disease progression (Commissioning Guide: Glaucoma)
Low/medium risk patients offered community monitoring
- phased implementation over 5 years
Patient offered choice of accredited practices
- patient records will be uploaded to a online portal and allocated to chosen practice
Patient attends for clinical review
- optometrist will re-evaluate the patient’s risk of conversion to COAG and risk of sight loss (NICE NG 81)

10. Integrated Glaucoma Monitoring Service
How will it work?
Optometrist makes management recommendation via IT portal (NICE NG 81)
No change – continue same management and see again in community in [X] months.
Suspicious sign(s)/uncertainty – discuss with consultant to inform decision
No longer meets monitoring criteria – discharge
Disease progression – send back to HES for consultant review
Recommendation ratified via IT portal
- consultant ophthalmologist (or a reviewer delegated by the consultant).
7. Patient advised of the outcome
- recalled to appropriate clinic at appropriate time (NICE NG 81)

11. Integrated Glaucoma Monitoring Service
Phased Approach
Phase 1
- patients currently attending the HES with low risk glaucoma related conditions (circa 20% of the total) will be monitored by optometrists in primary care
- virtual supervision provided by consultant ophthalmologists while the optometrists work to obtain a higher qualification in glaucoma.
Phase 2
- the role of the optometrists will be expanded to monitor and manage medium risk patients under virtual supervision while undertaking further specialist qualifications
- optometrists will manage an increasing number of patients autonomously as they gain further qualifications and the necessary experience
Anticipated up to 60% of patients with glaucoma related conditions could be monitored in the community by Year 5.

12. Role
Key responsibilities
Lead Consultant
overall clinical responsibility and professional accountability for the service
provide strategic leadership for the service
provide clinical supervision for optometrists and other HCPs in the service
lead MDT peer discussion meetings to review cases
ensure failsafe processes are working effectively
Clinical Governance Optometrist
analyse monthly performance reports and feedback from the Lead Consultant to identify optometrists that may require performance management/support
Implement performance management measures and action plans
identify training needs and implement training
organise targeted peer discussion sessions with the Lead Consultant
design communications to keep optometrists updated
Failsafe Officer
maintain and monitor register of review patients and appointment due dates
monitor and manage DNAs to ensure patients are aware of the importance of attending their follow appointments
monitor the list of patients who are referred back to the consultant clinic from the community due to disease progression to make sure they are offered an appointment within the agreed timescales

13. Integrated Glaucoma Monitoring Service
People with OHT, suspected COAG or COAG should have monitoring and treatment from a trained healthcare professional who has all of the following:
a specialist qualification
relevant experience
ability to detect a change in clinical status [2009, amended 2017]

14. Integrated Glaucoma Monitoring Service
Healthcare professionals involved in the monitoring and treatment of OHT, suspected COAG and established COAG should be trained to make management decisions on all of the following:
risk factors for conversion to COAG
coexisting pathology
risk of sight loss
monitoring and detecting a change in clinical status (for example, visual field changes, stereoscopic slit lamp biomicroscopic examination of anterior segment and posterior segment)
pharmacology of IOP-lowering drugs
treatment changes for COAG, suspected COAG and OHT (with consideration given to relevant contraindications and interactions). [2009]

15. Integrated Glaucoma Monitoring Service
People with a confirmed diagnosis of OHT or suspected COAG and who have an established management plan may have monitoring (but not treatment) from a suitably trained healthcare professional with knowledge of OHT and COAG, relevant experience and ability to detect a change in clinical status. The healthcare professional should be able to perform and interpret :
Goldmann applanation tonometry (slit lamp mounted)
standard automated perimetry (central thresholding test)
central supra-threshold perimetry (this visual field strategy may be used for monitoring OHT or suspected COAG when the visual field is normal)
stereoscopic slit lamp biomicroscopic examination of the anterior segment
van Herick peripheral anterior chamber depth assessment
examination of the posterior segment using slit lamp binocular indirect ophthalmoscopy. [2009]

16. Recap on Learning Objectives
1.2.4 Explain to patients the implications of their eye condition and the importance of adherence to the management plan set by the ophthalmologist before their referral to the community monitoring service
NG 81
Offer people the opportunity to discuss their diagnosis, referral, prognosis, treatment and discharge, and provide them with relevant information in an accessible format at initial and subsequent visits.

17. Recap on Learning Objectives
1.2.5 Communicate effectively with ophthalmologists and other clinicians involved in the care of patients with glaucoma
Online portal to exchange information
MDT peer discussion meetings to review cases
Clinical placements
NG 81
Ensure that all of the following are made available at each clinical episode to all healthcare professionals involved in a person's care:
records of all previous tests and images relevant to COAG and OHT assessment
records of past medical history which could affect drug choice
current systemic and topical medication
glaucoma medication record
drug allergies and intolerances. [2009]

18. Recap on Learning Objectives
Work collaboratively with colleagues within other healthcare professions in the best interest of patients with glaucoma ensuring communication is clear and effective
Online portal to exchange information
MDT peer discussion meetings to review cases
Clinical placements
NG 81
Ensure that all of the following are made available at each clinical episode to all healthcare professionals involved in a person's care:
records of all previous tests and images relevant to COAG and OHT assessment
records of past medical history which could affect drug choice
current systemic and topical medication
glaucoma medication record
drug allergies and intolerances. [2009]

19. Recap on Learning Objectives
Understand when referral to a consultant ophthalmologist is clinically justified and in the best interests of the patient
NG 81
People with COAG, suspected COAG and OHT
At each assessment, re-evaluate risk of conversion to COAG and risk of sight loss to set time to next assessment. [2017]

20. Recap on Learning Objectives
Refer for further investigation and diagnosis of COAG and related conditions, after considering repeat measures if:
there is optic nerve head damage on stereoscopic slit lamp biomicroscopy or
there is a visual field defect consistent with glaucoma or
IOP is 24 mmHg or more using Goldmann-type applanation tonometry. [2017]
Do not base a decision to refer solely on IOP measurement using non-contact tonometry. [2017]
Do not refer people who have previously been discharged from hospital eye services after assessment for COAG and related conditions unless clinical circumstances have changed and a new referral is needed. [2017]