Glaucoma referral refinement in Ireland: managing the sensitivity‐specificity paradox in optometric practice

Abstract

Of the patients seen within the scheme, 62% did not require referral onward to ophthalmology, thus releasing the significant majority of hospital clinic slots that would previously have been required to examine such patients. The high level of inter-professional decision agreement likely reflects the benefits of pre-scheme apprenticeship style training and ongoing hospital clinic participation by the scheme optometrist. The rate of loss to follow up compares favourably with ophthalmology led, hospital based, glaucoma clinics. Nevertheless, the losses indicate that patient education remains a key priority for future planning.

Accurate, fast, data efficient and interpretable glaucoma diagnosis with automated spatial analysis of the whole cup to disc profile

“…In the UK, approximately 80% of referrals to the hospital eye service originate from routine sight tests by optometrists in the primary eye-care service. However, only about 33% and 38% of routine suspect glaucoma referrals are subsequently found to have glaucoma in the UK [2] and Ireland respectively [3].…”

Care pathways for glaucoma detection and monitoring in the UK

“…in the strict sense of the need for such services to include testing sufficient for a diagnosis of glaucoma and to be delivered by appropriately accredited practitioners in accordance with NICE); however, it is clear that the 'referral refinement' term was used historically for many years to describe some GRFSs before NICE guidance was published, for example the original Manchester scheme 8 . Furthermore, the term referral refinement is still used to describe some GRFSs in other countries, for example, the Carmarthenshire GRRS, a scheme without inclusion of gonioscopy 9 , or in a jurisdiction where NICE does not apply, for example, the 'referral refinement' scheme described by Barrett et al 10 to ~15 "glaucoma referral refinement" schemes in self-evidently far fewer regions, and where strictly speaking, as implied above, many of which are likely to be representative of the GERS model versus true GRRS as the term has now come to be defined. From the stakeholder perspective, patients and others including commissioners appear to respond positively to these community services 12,13 .…”

Referral in a routine Italian optometric examination: towards an evidence-based model.

“…These include intermediate centres between the referring practitioner and ophthalmologists, in which specifically trained optometrists reassess the actual need for a referral by repeating essential clinical tests and/or performing additional procedures. Implementations of refinement schemes have widely demonstrated improvements to the quality of referral, reducing the number of false positives and therefore unnecessary demands on already overstretched ophthalmological sectors (H. Baker et al, 2016;Barrett et al, 2018;Ratnarajan et al, 2013). Patients referred because of a 'negative OSI' would seem particularly suitable for utilising similar schemes, perhaps run in close collaboration between ophthalmology and optometry, upon further and specialised training.…”

“…Such changes could be targeted to enhance the overall ability of optometrists in case detection, with considerable contribution to the reduction of unnecessary referrals of healthy people. More collaborative eye-care models are increasingly proposed worldwide to alleviate the workload on ophthalmologists, due to increased demand not adequately matched by a similarly growing capacity (Barrett et al, 2018;George et al, 2019;Mets et al, 2012). Nonetheless, both mentioned approaches would require formal assessment of their feasibility as well as of the associated cost-effectiveness.…”