glaucoma referral refinement.5.9.11.ppt - loc-net.org.uk · current position •all suspect...
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Glaucoma Referral Refinement: Glaucoma Referral Refinement: Bob Wilkes
Chairman
Central Mersey Local Optical Committee
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Current Position
• All suspect glaucoma referred to secondary care due to constraints of GOS sight test
• Low prevalence: Only 4 in 10 referrals are • Low prevalence: Only 4 in 10 referrals are positive (Still 97% sensitivity)
• NICE Guidance: Lower IOP threshold
▫ Large increase in referrals
▫ Only addresses suspect IOP
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Nice Guidance
• About diagnosis and treatment
• Not about referral
• Goldmann standard• Goldmann standard
• No fields standard!
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Referral Refinement
• Repeating tests:
▫ Increases specificity and sensitivity
▫ Increase in true positives
• LOCSU 1a• LOCSU 1a
▫ Applanation Tonometry
▫ “Gold Standard”
• LOCSU 1b
▫ Repeat suspect fields
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Applanation Tonometry (AT)
• Tends to read lower that NCT
• >70% Deflection rates
• Goldmann type• Goldmann type
▫ KAT acceptable
• Perkins allowed
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Tonometry workshop
• Core competency
• No accreditation required
• Mentoring • Mentoring
• Get started
• Brush up rusty skills
• Practice on model patients
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Visual Field Refinement
• Suspicious visual field at sight test• Repeat measurement on a separate occasion• Equivalent or higher level • Equivalent or higher level strategy▫ Defect confirmed: Refer▫ Improvement: Recall for further ST in 6 months
▫ No defect: Recall in 12 months
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Visual Field assessment
• Computerised test
• Supra-threshold/Threshold
• Threshold for repeat• Threshold for repeat
• Potential topic for lecture
• Coupled with Optic nerve head assessment
• New technologies: OCT/HRT.
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Referral exclusions
• Joint Colleges advice:
• Patients aged 80 years and over with measured IOPs < 26mmHgIOPs < 26mmHg
• Patients aged 65 and over with IOPs < 25mmHg
• Where there is no other suspicion of glaucoma
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Some scenariosSome scenariosExperience from refinement in Halton & St Helens
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Patient A
• Discs and fields suspect
• Glaucomatous signs
• Family History of • Family History of Glaucoma
• IOP: 25mmHg with NCT
• Refer to HES
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Patient B
• Any age• Discs and fields normal• Angles normal (van Herrick)• IOP: 25mmHg with NCT• IOP: 25mmHg with NCT• Repeat with AT▫ IOP: 21mmHg
• Recall in 12 months
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Patient C
• 62 years old• Discs and fields normal• Angles normal (van Herrick)• IOP: 25mmHg with NCT• IOP: 25mmHg with NCT• Repeat with AT▫ IOP: 23mmHg
• Refer to HES• If patient>65: don’t refer • If patient >80: only refer if
final IOP is >25mmHg
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Patient D
• Suspect Discs
• IOP: 20mmHg
• Supra-Threshold Fields:• Supra-Threshold Fields:
▫ Possible defect
• 1 week later
▫ Threshold Fields: Normal
• Recall in 6 or 12 months
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Patient E
• Suspicious Discs
• IOP: 23mmHg with NCT▫ 21mmHg on repeat with AT▫ 21mmHg on repeat with AT
▫ Supra-threshold Fields: Possible defect
• <2 weeks later▫ Threshold Fields: Defect
confirmed
• Refer to HES
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Benefits for the Patient
• Choice
▫ Venue and time
• Convenience
▫ Care close to home▫ Care close to home
• Speed of access
▫ Early intervention
• Quality▫ Core competency
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Benefits for GP Practice
• Simple referral process
• Local choice
• Fits ‘Choose and Book’• Fits ‘Choose and Book’
• Rapid access
• Reduction in GP consultations
• Retaining patients in primary care where appropriate
• Cost benefits
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Summary
• Reduction of unnecessary HES appointments, reducing patient anxiety, and generating capacity in hospital clinicsgenerating capacity in hospital clinics
• Ensuring secondary care availability of follow up care for those with established disease
• Cost effective service with more patients managed within primary care
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Some figures
Cases Not referred Fees HES
LOCSU 1a 12 11 £180 £2,189
Patients seen since October 2010
LOCSU 1b 11 8 £275 £2,189
23 19 £455 £4,378
Saving £3,923
Times 25 £98,075
Less FU £57,825
Estimate £75,000
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Thanks you for listening
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Glaucoma Referral Refinement: Glaucoma Referral Refinement: Bob Wilkes
Chairman
Central Mersey Local Optical Committee