Patient Centered Care of glaucoma through inter-professional collaboration

On Sunday 11Apr2010 I had the opportunity of speaking with a fairly large gathering of Optometrists from across British Columbia at a conference they were holding at the UBC Eye Care Centre. I was invited to talk about how best to work together in caring for patients with glaucoma as well as an update on my practice. This was an exciting opportunity given my involvement with this blog that Dr Hom and I started that deals with that very subject, as well as my work on the Canadian Glaucoma Society's (CGS) subcommittee on Inter-professional care of patients with glaucoma.

I am including the Keynote slides that I used for the talk below but what was far more important was the interaction with the audience for this session. The CGS guidelines are still in draft form and took the committee headed by Dr Marecelo Nicolela at Dalhousie University more than one year to get to this far. They have been approved by our committee but await discussion at our CGS Annual Meeting in June 2010. That being said, it is vital to be in constant communication with our Optometric colleagues in order to keep our glaucoma patients at the centre of their care.

After introducing the topic, I led an open discussion with the audience to better understand the practice patterns of current optometrists in our province as it pertains to the care of patients with glaucoma. As expected, there is quite a lot of variability likely dictated by two key factors: urban vs rural and Canadian vs American training. Perhaps oversimplifying our discussion, those Optometrists practicing in a rural setting are often not able to get patients the care they need for their patients because there are fewer ophthalmologists and no glaucoma specialists at all. Those Optometrists who trained in the United States were more likely to have a background in therapeutics whereas this has been less emphasized in Canada. Another statistic tossed around related to the decreasing role of Optometrists in dispensing glasses but this was a bit harder to measure with many Optometrists giving up the dispensing but practicing inside or directly next door to a major optical chain.

Patients who are suspected of having glaucoma or who have early glaucoma that is stable, especially if they live in a rural setting, are likely to need Optometrists to be intricately involved in initiating glaucoma therapeutics due to limited access to general and sub-specialized Ophthalmologists. As it is now in BC, they are either not receiving any initial therapy or some Optometrists have a close relationship with Family Doctors who they ask to initiate therapy until the patient can see a nearby general Ophthalmologist.

Patients in urban settings in BC, that is, Vancouver, are more likely screened by Optometrists and referred to glaucoma specialists. With our aging population, this may not be a sustainable model. As we have discussed in this forum before, Ophthalmologists are needed for the more advanced stages of the disease and if they spend too much time screening or treating patients very early in the course of glaucoma, they will not be available to handle the patients who need surgery.

We did discuss though an interesting conundrum, and perhaps those reading this article would like to add their opinions in the comments section. In order to adequately treat someone with a medical condition such as glaucoma, it is important to be very familiar with not just the diagnosis of disease and its progression, but also with the treatment options at different stages of the disease. An Optometrist in the audience asked where I fitSelective Laser Trabeculoplasty (SLT) into the treatment regimen. Laser is alteration of tissue and therefore it is surgery; this is not going proposed as a modality of treatment that Optometrists will provide if/when they get therapeutics. As myself and other colleagues do perform SLT as first or second line therapy, should an Optometrist be presenting this as an option as a first or second line therapy to their patients? Absolutely! Patients need to be aware of ALL reasonably accepted options for treatment, their side effects, and the alternatives including what would happen if they were not treated. For those treatment options that they cannot provide themselves, they need to refer to someone who can...whether this is a general or sub-specialized Ophthalmologist or a treating Optometrist. (We will likely see in Canada some Optometrists comfortable with medical treatment, some specialized in Glaucoma, and others who are not comfortable with initiating treatment.)

From our open discussion, we were in agreement that any eye care professional needs to know what they are comfortable treating and when it is time to refer onward either for confirmation of the current management or additional medical or surgical therapy. I did point out a bit of irony in that these guidelines to date were drafted by a group of glaucoma sub-specialists, to suggest how Ophthalmologists (never specifying glaucoma specialists) and Optometrists should work together in keeping the glaucoma patient in the centre of a model of inter-professional care. However, no general ophthalmologists or optometrists were involved yet in these guidelines. That is of course why these talks are now beginning over the next few months to open the dialog between Ophthalmologists and Optometrists. On reflection, it does make sense that we had to start somewhere so getting our CGS group to put together this initial draft does make sense.

In order to standardize the care, the guidelines do propose some minimum skills for eye care professionals involved in caring for patients with glaucoma. This includes performing Goldmann-type applanation tonometryas the accepted gold standard (likely Pascal will also become acceptable) but that Tonopen and pneumatic tonometry are not acceptable. Gonioscopy and stereoscopic assessment of the optic nerve are both minimum required skills in diagnosing patients with glaucoma. Furthermore, an understanding of what constitutes progression on Visual Field testing is vital to know if a glaucoma suspect is progressing to glaucoma or a patient with established disease is progressing. Full threshold testing is required so that those Optometrists who just have FDT machines can only screen but can't diagnose new disease or look for progression. We discussed that those Optometrists who have one or more of these minimum skills are certainly qualified to diagnose patients and follow patients early in the course of glaucoma. 

As the glaucoma staging moves from screening, suspecting, early glaucoma and more advanced disease, the need to consult with an Ophthalmologist increases. There are differing degrees of Ophthalmologists involvement proposed depending on where in this continuum the patient lies. This section of the guidelines serves to put into words what would seem to be intuitively obvious to both Optometrists and Ophthalmologists. That being said, there will still be a lot of variability based on urban vs rural and Canadian vs American training. These guidelines are still in draft form and are, just that, guidelines. We need further input from those not yet involved in this document's creation, namely Optometrists and general Ophthalmologists. This process is underway and your comments on this blog would be very helpful to help us better care for glaucoma patients.

To add further insult to injury, our health minister was recently quoted as saying on national radio that there are no eye diseases that are asymptomatic so our province is looking at no longer covering routine eye examinations. Kevin Falcon clearly knows nothing about glaucoma; screening can detect disease before it becomes symptomatic so our patients need never lose vision to glaucoma. Sadly, our best data is still that half of patients with glaucoma don't even know they have it. We need to be able to work together as eye care professionals to care for patients with all stages of glaucoma.

The following comments were copied from original submission dates and posted as a journal follow-up article in preparation for changing to DISQUS for future commenting on my blog.)

29Apr2010 reader comment:
First of all I'd like to thank you for this blog. I feel collaboration between Optometrists and Ophthlamologists is of great benefit to our patients.

As a Canadian (UW '01) trained optometrist there is one quote from above that sprung out at me:

"As expected, there is quite a lot of variability likely dictated by two key factors: urban vs rural and Canadian vs American training..... Those Optometrists who trained in the United States were more likely to have a background in therapeutics whereas this has been less emphasized in Canada."

It is my understanding that the training we receive in Canada is quite parallel to that of the US. During my training it was mandatory to spend a term (12weeks) on a "US externship" during our 4th year. 

At that time I had the good fortune of training at an ophthalmological referral centre in Baltimore, MD. While there I learned from glaucoma, cornea/cataract and retinal sub-specailized ophthalmologists as well as ocular health sub-specialized optometrists. My time spent was actually greatest with the glaucoma specialist as he had the most clinic hours at the site. It is during this experience that I developed my love/hate relationship with the Humphrey visual field analyzer, I love to interpret the results but hate to administer the test, lol.

Interestingly while in Baltimore we also worked with 4th year students from Illinois College of Optometry (Chicago) while they had seen more glaucoma at their college clinic than we had in the Waterloo, they had not seen any patients with AMD. I suppose this is due to the mainly African-american population their school clinic serves. Whereas in Waterloo seeing patients with AMD of all stages was a very common occurrence.

I guess my point is that Canadian trained Optometrists may very well be on the same level of the the playing field in regards to therapeutic treatment of patients. I have the fortune of practicing in a province (NB) where I have been able to prescribe all topical (except glaucoma, only allowed in emergency situations) therapeutics since my graduation. I can therefore keep that skill set sharp in practice.

Again, thank you for the blog and I look forward to following it.

Michelle Lane, OD

29Apr2010 my reply:
Thank you so much for your comments that help to clarify training similarities between the US and Canada. My apologies if it sounded like I was offending the training here. My points were based on a straw poll of the audience in attendance at this recent meeting. I am guessing that it could be biased if most of the American trained Optometrists at the meeting graduated more recently than those trained in Canada (who have not been able to practice therapeutics much) so the Canadian trainees are further out from their training and now have to re-learn therapeutics. Since Canada cannot train enough optometrists on its own to meet the eyecare needs, at least here in BC, many have ventured south of the border for training in recent years.
Robert M Schertzer, MD, MEd, FRCSC

29Apr2010 my co-editor's comments:
Drs Schertzer and Lane,

I wonder if we could see a parallel in Canada as we do here in the US. 

In the US, the rural optometrist is often more likely to collaborate and/or manage eye disease to the fullest extent of their training and scope of practice regulation.  Their interest drives them to maintain currency in their continuing education and skills wherever that education might be.  

On the other hand, except for a few circumstances, urban optometrist have much less incentive and opportunity to practice "full-scope" (to the limit of their law/regulation) optometry because of the plentiful number of ophthalmologists.

Having myself practiced as an "attending optometrist" at my local public safety net hospital, I was afforded the opportunity and encouragement of the ophthalmology and internal medicine staff to practice full scope. 

Do you both see a parallel in Canada or in this case British Columbia between urban and rural optometrists?
Richard Hom OD FAAO

29Apr2010 another reader comments:
Thank you Dr. Schertzer for your open discussion and blog.  I do agree with your comments, and as well, your observation of the optometrists at attendance during the recent meeting.  I would confirm that you are correct in stating that many recent Optometry graduates, perhaps within the last 15 years, from both Canada and the USA are now well trained with therapeutics.  Their education contains a very strong emphasis on ocular health.  I would venture to say that most are comfortable and also expect or hope to co-manage with MDs.  Perhaps only in BC, has this opportunity been unreasonably restricted.  Coming from WA state, the issues and attitudes that Canada seem to only now be slowly going through appears to be something that the USA has already progressed past a while ago.  Hopefully in order to stop the changes that Minister Falcon has decided to implement will then bring more ODs and MDs together for the sake of their patients, and create further discussions like yours.  Sadly, the public, whom we all  serve together are now at risk because of this irresponsible de-regulation.

Vivian Yeung, OD