The challenges of glaucoma

The publication of the NICE guidance on glaucoma in 2009 had an unintended consequence - and created a tidal wave of referrals .

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Author: Daniel Hardiman-McCartney MCOptom, Clinical Adviser
Date: 31 March 2015

Many Optometrists will remember April 2009, when the National Institute for Clinical Effectiveness (NICE) issued its first tome of glaucoma guidance. From that day onwards the way we thought about glaucoma changed. For those affected by glaucoma, the guidance recommended best practice and standardisations across the country, surely a good thing.

However there was an unintended consequence: as a result of the guidance, the AOP, ABDO and FODO recommended to all their members, for legal defence reasons, that any patient with pressures over 21mmHg should be referred for an ophthalmological review, even if other findings (in particular discs and fields) were normal. This created a tidal wave of new referrals, many false positive outcomes and a shattering of trust with both our patients and our ophthalmologist colleagues. In the face of what we knew about early detection of glaucoma, referring those patients on pressures alone seemed patently wrong.

With increasing numbers of optometrists taking the College’s higher level qualifications in glaucoma, optometrists are undoubtedly capable of robustly diagnosing and excluding glaucoma

So six years on where are we? Well to answer that you need to read the new edition of Ophthalmic and Physiological Optics (OPO) a special virtual edition devoted to Glaucoma. Thirteen papers, all relating to the optometric case detection of Glaucoma, where we are now and where we should be going in the years to come. Ophthalmic and Physiological Optics is a highly respected academic journal, but don’t think for one minute it’s not relevant to practice, let me tell you it certainly is! For researchers this issue provides a wealth of the latest work to digest and inspire, but for those less familiar with this territory, you should start by reading Prof John Lawrenson’s excellent editorial, describing the insidious nature of glaucoma and an easy to read summary of each of the papers published. A paper of particular interest to me was that by Black et al, investigating the functional outcomes of those with visual field defects, a thought provoking read for all. 

Be warned, good science sometimes make for tough reading: for example, the quality of optometrists’ referrals is called into question with papers adding to the wider debate on the topic. Obviously it is disappointing for any professional to see colleagues not performing to the high standards that are incumbent upon us, but we cannot ignore these findings simply because they are uncomfortable. As professionals we must acknowledge our weaknesses, examine their causes and seek to find solutions.  

The OPO special edition lays out the huge challenge that lies ahead. Getting those people into practice who currently do not access primary eye care services, who are likely to be those who are most at risk of conditions such as glaucoma. Becoming more consistent in what we do as a profession to detect glaucoma and to report it well. Finally, commissioning robust services which are truly patient focused and which go beyond calling a number above or below 21.

With increasing numbers of optometrists taking the College’s higher level qualifications in glaucoma, optometrists are undoubtedly capable of robustly diagnosing and excluding glaucoma, in addition to working as part of an interdisciplinary team delivering ophthalmologist-led community care services. This edition of OPO will be important in the years to come, informing tomorrow’s policy and scoping our practice: read this special edition and join the conversation.

Useful links:

Glaucoma: Diagnosis and management

College guidance on examining patients at risk from glaucoma

Daniel Hardiman-McCartney FCOptom
Clinical Adviser, The College of Optometrists

Daniel graduated from Anglia Ruskin University, where he won the Haag Strait prize for best dissertation. Before joining the College, he was Managing Director of an independent practice in Cambridge and a visiting clinician at Anglia Ruskin University. He has also worked as a senior glaucoma optometrist with Addenbrooke’s Hospital in Cambridge, with Newmedica across East Anglia and as a diabetic retinopathy screening optometrist. Daniel was a member of Cambridgeshire LOC from 2007 to 2015 and a member of the College of Optometrists’ Council from 2009 to 2014, representing its Eastern region.  

He is Clinical Adviser to the College of Optometrists for four days each week, dividing the remainder of his time between primary care practice and glaucoma community clinics. Daniel is a passionate advocate of the profession of optometry, committed to supporting all members of the profession and ensuring patient care is always at the heart of optometry. He was awarded Fellowship by Portfolio in December 2018.


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