What is a Glaucoma “Suspect”?

Yvonne Ou, MD

University of California, San Francisco, UCSF Medical Center

• Expert Advice

Published on:

July 9, 2021

A glaucoma “suspect” usually comes to the attention of an eye doctor for several reasons: the eye pressure is found to be elevated above “normal,” there is a strong family history of glaucoma, or the optic nerves have an appearance that is suspicious. It is also possible for a patient to be called a glaucoma suspect due to the presence of several risk factors. However, a definitive diagnosis of glaucoma is often made over time, since most forms of glaucoma are slowly progressing.

GLAUCOMA “SUSPECT”

A glaucoma “suspect” is an individual who demonstrates one or more factors that put them at higher risk of a glaucoma diagnosis, but do not yet have glaucoma damage. Sometimes this is referred to as pre-glaucoma or borderline glaucoma.

Characteristics of a glaucoma “suspect” include:

• High intraocular pressure (IOP) or ocular hypertension
• Unusual or defective visual fields
• Other optic nerve features suggestive of glaucoma

Once a baseline status is determined, periodic follow-up visits with the eye doctor are necessary to see if there are changes to the appearance of the optic nerve, the visual field, or to the internal eye pressure, for example. For the purposes of this article, the topic is limited to the “open-angle” glaucoma “suspect.” In open-angle glaucoma, which is the most common form of glaucoma, the drainage angle has a typical open appearance. Another form of glaucoma, angle-closure glaucoma, is a separate entity and will not be discussed here.

The Eye Exam

To determine whether a patient is a glaucoma suspect, a full history and eye examination should be performed. The doctor will evaluate vision, the pupils, eye pressure, corneal thickness, and examine the front and back of the eye. There is also an examination of the drainage “angle” or drainage system of the eye by using a special lens with mirrors, and is called gonioscopy. It is important to determine whether the drainage angle is open or closed. Baseline visual field testing and optic nerve imaging is also obtained to more effectively assess the structure of the optic nerve.

Risk Factors for Glaucoma

Eye doctors also assess whether the patient has risk factors for glaucoma or has abnormalities of the eye that might provide clues as to a cause for the glaucoma. The risk factors for open-angle glaucoma include but are not limited to: increasing age, elevated intraocular pressure, ethnic background (African-American or Hispanic), family history of glaucoma, corticosteroid use (especially eye drops), and certain eye conditions such as nearsightedness or having a thin cornea.

Glaucoma “Suspect” Treatment Options

If you are a glaucoma suspect, the most important “treatment” is good follow-up care. Sometimes eye doctors are on the fence about whether to start treatment, and it is only through repeat follow-up visits that they get a sense of whether or not a patient really has glaucoma or not. Thus it is very important for patients to maintain follow-up care, and typically for a low-risk glaucoma suspect this may require visits every 6 to 12 months. At each follow-up visit your eye doctor will check your vision, eye pressure, and examine the front and back of your eye, paying careful attention to the appearance of your optic nerves. There are also tests that are commonly performed to assess the structure and function of the optic nerve. To examine the structure of the optic nerve, your doctor will perform a careful examination in the office, obtain optic nerve imaging, and obtain a baseline set of optic nerve photographs. To examine the function of the optic nerve, an automated visual field test we be implemented with the help of a technician, who will instruct you on the correct way to perform the test. All of these tests may be repeated at yearly intervals (or more or less frequently, as determined by your eye doctor) to assess if there are changes or “progression” over time. The follow-up visits are crucial to maintaining optimal eye health.

Initial treatment options include either topical eye drops or laser treatment of the drainage angle to increase the amount of fluid draining from the eye, both of which can lower the eye pressure. The decision to treat is often not a cut and dry one; your ophthalmologist will assess all of your risk factors, your examination findings, and seek your input as to whether to treat or continue to observe your eyes over time. Some patients prefer to “watch and wait” or are worried about the side effects of treatment, while others may be more risk averse and would rather begin treatment and have peace of mind. There are some glaucoma risk calculators available but most eye doctors would agree that these may aid in diagnosis and assessment, but will not replace your doctor’s clinical judgment.

Questions to Ask Your Eye Doctor if You are a Glaucoma “Suspect”

The following are good questions to ask your eye doctor:

• Is my eye pressure elevated?
• Are there abnormalities to my optic nerve or field of vision?
• What are my risk factors for open-angle glaucoma?

As you build a relationship with your eye doctor and continue appropriate follow-up care as a glaucoma “suspect,” the decision concerning whether to begin treatment or not will become clearer. The good news is that if glaucoma treatment is required and begins early when there is little or no damage to the optic nerve, the risk of serious vision loss is quite small.
 

About the author

Yvonne Ou, MD

University of California, San Francisco, UCSF Medical Center

Yvonne Ou, MD, is a board certified ophthalmologist who specializes in glaucoma, including medical, laser and surgical therapies; cataract evaluation and treatment including combined cataract and glaucoma surgery; glaucoma filtering and implant surgery; and newer procedures.

Full bio

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Glaucoma suspects: A practical approach

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Algorithms for the management of patients with open-angle glaucoma A»

GLAUCOMA

Training manual

for ophthalmologists, clinical residents and interns

Moscow

2016

A45

Compiled by:

Head of the Department of Ophthalmology FGBOU DPO IPK FBMA of Russia .n. Professor Trubilin V.N.

Professor of the Department of Ophthalmology FGBOU DPO IPK FBMA Russia Kozhukhov A. A.

Head of the ophthalmological department of the State Budgetary Institution of Health “Scientific Research Institute – Regional Clinical Hospital No. 1” named after. prof. S.V. Ochapovsky of the Ministry of Health of the Krasnodar Territory (GBUZ NII-KKB No. 1 named after Prof. S.V. Ochapovsky of the Ministry of Health of the Krasnodar Territory), Associate Professor of the Department of Eye Diseases of the Kuban State Medical University of the Ministry of Health of Russia (GBOU VPO KubGMU of the Ministry of Health of Russia) Dr. m.s. Malyshev A.V.

Ophthalmologist GBUZ NII-KKB No. 1 named after. prof. S.V. Ochapovsky of the Ministry of Health of the Krasnodar Territory, Associate Professor of the Department of Eye Diseases, Kuban State Medical University of the Ministry of Health of Russia, MD. Yanchenko S.V.

Ophthalmologist GBUZ Research Institute-KKB No. 1 named after. prof. S.V. Ochapovsky of the Ministry of Health of the Krasnodar Territory Associate Professor of the Department of Ophthalmic Diseases, Kuban State Medical University of the Ministry of Health of Russia Lysenko O. I.

Reviewers:

Chief Physician of the Excimer Eye Clinic,

Doctor of Medical Sciences, Academician of the Russian Academy of Natural Sciences and RAMTS,

Honored Doctor of the Russian Federation Kashnikov V.V.

Head of the Department of Traumatology and Orthopedics Afaunov AA.

“Algorithms for the management of patients with open-angle glaucoma”: a textbook. – Moscow, FMBA, 2015. – 16 p.

leading causes of low vision and blindness worldwide. Compiled in accordance with the exemplary program in ophthalmology for postgraduate training. It is intended for doctors, clinical residents and interns to facilitate and speed up decision-making on the diagnosis and treatment of patients with glaucoma. The manual can be used during practical exercises to facilitate the process of learning and memorization.

Recommended for publication by the Academic Council of FGBOU DPO IPK FMBA of Russia,

protocol No. ______ 2016

FOREWORD

9 0030 Glaucoma is a disease with a chronic course and a serious prognosis, which is one of the main causes of low vision and blindness in all over the world. The problem of diagnosis and treatment of glaucoma is currently still far from a final solution.

Purpose of developing a training manual.

This manual summarizes the current understanding of open-angle glaucoma, based on literature data and the results of practical and scientific work of the staff of the Department of Ophthalmology FSBEI DPO IPK FMBA of Russia and the ophthalmological department of GBUZ NII-KKB No. 1 named after. prof. S.V. Ochapovsky Ministry of Health of the Krasnodar Territory. Algorithms for managing patients with glaucoma are presented in the form of color tables based on the methodology of neurolinguistic programming. Such a presentation of information helps to quickly assimilate the material and choose the right tactics in a situation of a time-limited appointment with an ophthalmologist.

RELEVANCE

Glaucoma occupies one of the ranking places as a cause of visual impairment and steadily keeps at the level of 14-15% in Russia and developed countries of the world (E.S. Libman et al., 2008; A.P. Nesterov 2008; Islamova S. E. et al., 2004; W. M. Tanget al., 2000).

Over the past decades, new methods for diagnosing surgical and medical effects in glaucoma have been proposed (S.E. Avetisov et al., 2005; L.F. Linnik et al., 2005; JWeer et al., 1998). However, the effectiveness of treatment and currently remains insufficient, because. does not exceed 50% (T.O. Eliseeva et al., 2000; L.A. Katsnelson et al., 1998; S.S. Naugesh, 2001).

The traditional interest of ophthalmologists in this problem is explained by the significant frequency of glaucoma, the great variety of its clinical forms, the difficulties of early diagnosis and treatment (VV Volkov et al., 2005, Friedman S.et al., 2004). Therefore, the development of correct tactics for diagnosis and treatment is very relevant.

ALGORITHMS FOR MANAGEMENT OF PATIENTS WITH GLAUCOMA

1

fig. 2

fig. 3

fig. 4

fig. 5

fig. 6

fig. 7

Fig. 8

To make a diagnosis, it is sufficient to determine the narrowing of the field of peripheral vision and the level of IOP.

In the first stage, the field of peripheral vision is not changed. Scotomas are not taken into account, because in this period they are rare, and their etiology needs to be clarified. We propose to exclude the assessment of the condition of the OD excavation from the classification criteria for the time being, because its visual (ophthalmoscopic) assessment is extremely subjective, and the equipment of most clinics in the Russian Federation does not allow for more expensive studies.

The criterion for the transition from the third stage to the fourth is the loss of central vision. The loss of central vision should be the reason for the termination of surgical treatment aimed at preserving visual functions (LTP, NGSE, STE, etc.) and the transition to interventions aimed at the prevention and relief of pain (hypotensive polytherapy, additional drug treatment, laser or cryocyclodestruction, alcoholism, etc.).

We propose to consider objective non-contact tonometry as a reliable way to measure true intraocular pressure. Any subjective contact methods are outdated today, have a risk of infection, injury, require significant time, etc.

In determining the level of IOP, we propose the following changes – to divide the concept of the norm into two types – the norm for healthy (Ab) and the norm for patients (Aa). The norm for healthy people remains at a level below 22. The norm for patients with glaucoma is taken at the level of 12–18, in order to reduce confusion, equate the concept of the norm for patients with the concepts of target pressure and tolerant pressure.

Transition of pressure level B to level C. We offer the following landmark – the possibility of performing laser intervention (trabeculoplasty). According to laser surgeons, with IOP above 35 mm Hg. this operation becomes almost impossible. Therefore, the degree of pressure increase B in the algorithms is fixed between 23 and 35.

Glaucoma is suspected when IOP rises to 20-30 mm Hg once. Art., in the absence of other changes in the field of view and in the fundus, characteristic of glaucoma. Suspicion should be removed or diagnosed within 7 to 12 months.

The standard for patients to visit an ophthalmologist 1 – 3 – 6 months is recommended in case of positive dynamics and stabilization of the disease for more than six months. If today the patient is compensated, it is simply not necessary to expect the appearance of any changes earlier than after 6 months (it is clear that there are rare exceptions).

The terms monotherapy and polytherapy are used in the scheme. The choice of specific drugs should be at the discretion of the attending physician.

We adhered to the following scheme. Treatment begins with drugs of first choice – prostaglandins or carbonic anhydrase inhibitors. If they are ineffective or poorly tolerated, they are replaced with medicines of another pharmacological group or switched to polytherapy.

Requirements for an optimal drug: an effective reduction in IOP, minimal daily fluctuations, a long-term hypotensive effect, a minimum of local and systemic reactions, and a simple dosing regimen. In our clinic, the drug of first choice is travoprost 0.004% (Travatan), which is a highly selective full FP-receptor agonist, one of the most effective and safe drugs for the treatment of glaucoma. In terms of its effectiveness, Travatan is not inferior, and in some cases exceeds latanoprost 0.005%.

The hypotensive effect of travoprost persists up to 84 hours after the last instillation. Since 2013, a new form of Travatan without benzalkonium chloride has been released, which ensures safe long-term treatment of patients with glaucoma.

For polytherapy, it is more expedient to use fixed combinations (Duotrav (travoprost 0.004% and timolol maleate 0.5%), Xalacom, Gunforth and Azarga (brinzolamide 1% and timolol maleate 0.5%), which provides high efficiency and convenience for patients.

The possibility of repeating laser operations is debatable. Despite the fact that a single LTP cannot always provide the desired level of IOP, we do not exclude the possibility of re-intervention in a month. For example, if after the first operation IOP could decrease to the desired numbers (from 33 mm Hg to 25) – repeated intervention can really solve the problem in this situation.

Laser surgery can be used in combination with conventional surgery. If an increase in IOP is observed only a year after LTP, it is also possible to do with a second laser operation.

Particular attention should be paid to the need for neuroprotective therapy in patients, treatment of comorbidities and conjunctival cavity. It is generally accepted that the main cause of the development of glaucomatous optic neuropathy is vascular problems. In situations where surgical intervention (NGSE, STE) was not effective enough, the decision on the next operation should be made only after a three-month course of patient treatment on an outpatient basis.

Algorithms developed prior to penetrating surgery. If it turned out to be ultimately ineffective, then further management of the patient is extremely difficult to algorithmize and the decision on further treatment should be made strictly individually, preferably with the involvement of several specialists.

ABBREVIATIONS

LTP – laser trabeculoplasty

NPSE – non-perforating deep sclerectomy

STE – sinustrum beculectomy

BASIC REFERENCES

Egorov E.A., Astakhov Yu.S., Schuko A.G. / National guidelines for glaucoma for practitioners. – M.: GOETAR-Media – 2011.- 280s.

FURTHER LITERATURE

1. Alekseev V.N., Malevannaya O.A. conf.: Materials. – M., 2004. – S. 393-396.

2. Ermolaev S.V., Ermolaev A.V. . Issues of prevention and clinical examination among patients with glaucoma according to the data of a sociological study. //Glaucoma: reality and prospects: Vseros. scientific and practical. conf.: Materials. – 2008. – S. 139-142.

3. Erichev V.P . Modern principles of antihypertensive therapy of glaucoma //Glaucoma: reality and prospects: Vseros. scientific and practical. Conf.: Materials. – 2008. – S. 220-223.

4. Loskutov I.A . Klin. Pharmacology and therapy. – 1997. – No. 4. – S. 18-20.

5. Romanova TB, Romanenko IA Medical examination of glaucoma: past and

present // Klin. Ophthalmology. – 2007.- V. 8 – No. 2. – S. 75-78.

6. Ashburn F.S., Goidberg I., Kass M.A. Compliance with ocular therapy // Surv. Ophthalmology.- 1980 – Vol. 24. – P. 237-248.

Introduction…………..……………………………………………3

Relevance … ……………………………………………. .4

Schemes of algorithms for managing glaucoma patients………..5

List of abbreviations………………………… …………………14

References………………………………………………………………………15

Back to “Preparing for publication”

Diagnosis of glaucoma in optometric practice | Korneeva A.V., Isakov I.N., Kuroyedov A.V., Onufriychuk O.N.

Introduction

In the Russian Federation, about 65.5 million patients seek ophthalmological care during the year, which creates a heavy burden on the ophthalmological service [1]. The increase in the frequency of eye diseases leads to an increase in the demand for primary care and implies an increased role of optometrists in healthcare.

Optometry is a separate area of ​​professional activity aimed at protecting eye health, requiring special education and government regulation (for example, registration and licensing). An optometrist is a primary care professional in the field of vision and eye health, whose activities include the study of refraction of the eye, the selection of vision correction products for refractive errors and binocular disorders, the diagnosis and treatment of eye diseases, the care of non-surgical eye injuries, and visual rehabilitation (including orthooptic treatment) in patients with visual system disorders [2].

Optometric practice is not part of the healthcare system, but plays an important role in protecting the vision of the population, since patients who have applied for refractive errors can be diagnosed with ophthalmic diseases, in some cases at an early stage. An optometrist may be the only medical professional who is able to assess the condition of the eyes, provide first aid and refer you to an ophthalmologist, although his main task is to select the optical correction. Visual acuity testing is the first step in the examination and is of great importance in the diagnosis of eye diseases, visual symptoms and in the selection of optical devices for visually impaired patients.

Optometric practice also plays an important role in the early diagnosis of glaucoma, since often people over 40 who have not previously had vision problems turn to the selection of corrective means. And age over 40 years and refractive errors (myopia and hypermetropia) are risk factors for the development of glaucoma. Problems with near vision are experienced by almost the entire adult population of the planet over 50 years old, and the most common optical defect is presbyopia associated with a decrease in accommodation [1, 3].

Glaucoma is the leading cause of blindness in developed countries and is of great social and economic importance due to its wide and widespread prevalence, chronic course with a high percentage of irreversible blindness, and large expenditures of public funds for medical, social and household rehabilitation of patients. Taking into account the fact that 50% of patients with glaucoma are unaware of their disease and do not receive proper treatment, and in 40–80% of cases glaucoma in the Russian Federation is diagnosed in the late stages, improving the early diagnosis and treatment of glaucoma is an urgent task [3, 4] .

Thus, a significant prevalence of primary glaucoma and its asymptomatic course in the early stages, especially with a normal level of ophthalmotonus, determines the relevance of actions aimed at early detection of the disease [5].

Glaucoma screening in optometric practice

Primary open-angle glaucoma (POAG) is a chronic progressive optic neuropathy, which is characterized by: periodic or constant increase in intraocular pressure (IOP) above the individual norm, structural pathological changes in the optic nerve head (OND) and typical visual field defects with an open angle of the anterior chamber [ 6]. Thus, optometrists typically rely on a triad of tests to detect glaucoma, including assessment of structural changes in the ONH, functional visual field loss, and IOP.

The standard for equipping a cabinet for simple optical correction (since June 2020) includes a tonometer, and the standard for equipping a cabinet for complex and special correction, according to the order of the Ministry of Health of the Russian Federation dated June 9, 2020 No. 558n, includes a corneotopograph, which makes it possible to assess the central thickness cornea [7]. In practice, tonometry, biomicroscopy and ophthalmoscopy constitute the arsenal of an optometrist in the diagnosis of glaucoma. The professional standard of a specialist in the field of medical optics and optometry includes measuring IOP and determining visual fields. At the same time, to assess structural changes, specific methods for studying the optic disc are needed, and to determine functional disorders, standard automated perimetry (SAP) is needed, which are far from always available in optometric practice.

The feasibility of primary screening for glaucoma during an optometric appointment is of great interest to researchers in developed countries, and the experience of optometrists referring patients with suspected glaucoma for examination is constantly analyzed [8–21]. A number of studies have shown the low diagnostic value of tonometric data for glaucoma screening. Swedish scientists did not reveal glaucoma in individuals under 45 years of age during primary screening in terms of IOP level and its asymmetry in single and double measurements. However, the largest number of persons with glaucoma and advanced stages of glaucoma was found in the group of 70 years and older with a lower probability of a false positive diagnosis. The authors concluded that tonometry is not an ideal tool for the early diagnosis of primary glaucoma, since only the level of ophthalmotonus does not simultaneously have sufficient sensitivity and specificity, diagnostic capabilities should be enhanced by ophthalmoscopy followed by optical coherence tomography (OCT) of the optic disc and perimetry [11] . The results of the study by G. Ratnarajan et al. [12] also confirmed the conclusion about the low diagnostic value of tonometry and the combination of tonometry with perimetry in glaucoma.

The first domestic experience of glaucoma screening in optometric practice confirmed the low diagnostic and prognostic significance of tonometry in the diagnosis of glaucoma. According to I.A. Loskutova et al. [13], enhancement of the standard set of optometric diagnostics with a non-contact tonometer, a slit lamp with the possibility of ophthalmoscopy with a lens of 78 diopters, an ophthalmoscope, a computerized perimeter, and a Heidelberg retinal tomograph (HRT ΙΙ) made it possible to assess the detection rate and ratio of patients with POAG, its separate variant — low-grade glaucoma. pressure (GND) and ophthalmohypertension. After analyzing the data of 3620 examined, the authors found that glaucoma was suspected in 682 (18.8%) people. Among them, the diagnosis of POAG was confirmed in 132 (19.4%), including MLAs in 19 (14.4%). That is, the suspicion of glaucoma arose in relation to almost every fifth person who turned to an optometrist, and in almost every fifth case the diagnosis was confirmed. The proposed glaucoma screening model demonstrates the feasibility of using optometric technique as a primary link for identifying patients with primary glaucoma. At the same time, tonometry is necessary, but does not have sufficient specificity for effective screening. Strengthening the diagnostic capabilities of ophthalmoscopy followed by laser scanning ophthalmoscopy and perimetry significantly increases the information content of the examination. The data presented are consistent with the results of previous studies. The proportion of patients with a confirmed diagnosis of POAG in the total number of patients referred for examination with suspected glaucoma varies significantly. M. Tuck et al. [14] confirmed the diagnosis of glaucoma in 40% of cases, J.N. Sheldrick et al. [15] – in 32%, R.W. Bell et al. [16] — in 17%, S.A. Vernon et al. [17] — in 48%, D.K. Newman et al. [18] — in 43%, J. Theodossiades et al. [19] — in 22%.

The list of studies on the frequency of referral of patients with suspected glaucoma from optometry practices can be continued, but it is necessary to keep in mind the differences in results depending on the method of selecting patients. B. Bowling et al. [20] detected glaucoma in 20% of 2505 people referred for examination, and according to R.J. Harrison et al. [21], glaucoma was confirmed in 80% of patients referred by optometrists.

The problem of insufficient effectiveness of tonometry in the early diagnosis of glaucoma is often raised, but research in this direction continues, as new screening programs for primary glaucoma are compared with this diagnostic method. According to R.A. Harper et al. [22], the sensitivity of tonometry in the selection of patients with IOP more than 21 mm Hg. Art. estimated at 50% with a specificity of 97%. Similar data was shared by J.G. Daubs et al. [23].

L.A. Edwards et al. [24] conducted screening in UK shopping centers by measuring IOP and BP levels, the main task was to raise public awareness of the importance of these indicators. The main obstacle to early detection, diagnosis, adherence to treatment and prevention of glaucoma, according to the authors, is the lack of awareness about this disease. A more active public interest in the simultaneous measurement of these two indicators compared to the measurement of only ophthalmotonus was revealed. The researchers emphasized that more than 90% of referrals to healthcare facilities for glaucoma were initiated by optometrists.

According to British authors, 87% of 199 optometrists had access to the traditional triad of tests required to adequately detect glaucoma. Most often (13%) there was no opportunity to conduct SAP. Monocular direct ophthalmoscopy was indicated as the first method of choice by 64% of respondents, contact applanation tonometry was available to 47% of respondents, but only 14% of them used it as the first choice for routine eye examination. Of 73 optometrists with access to contact and non-contact tonometry, 80.8% preferred non-contact tonometry. The authors emphasized that although population-based screening for POAG is neither cost-effective nor practical, the disease is primarily detected during routine eye examinations. The priority in the diagnosis and treatment of glaucoma is patient education and awareness. Interest in improving the detection and treatment of glaucoma indicated 98% of optometrists, and 57% agreed with the need for additional postgraduate training to expand the scope of practice [25].

At the same time, A.J. Lockwood et al. [26] noted the low sensitivity and specificity of SAP, which disappointed researchers due to the large number of referrals to the ophthalmologist with false positive perimetry data and the lack of detection of glaucoma with the widespread use of perimetry. According to the authors, POAG was confirmed only in 7% of referred patients, ophthalmohypertension in 11%, and suspicion of glaucoma in 21% of those who applied. Tonometry has also proven to be an ineffective screening tool. The detection of glaucoma was significantly higher when assessing the state of the optic disc during indirect ophthalmoscopy.

L.H. Tsai et al. [27] suggested to detect eye diseases, including glaucoma, to study color vision and contrast sensitivity. We studied the effectiveness of optical correction and the relationship between optical correction, eye diseases, visual symptoms, and choice of optical device in patients with low vision. The most common eye diseases, according to the authors, were retinal diseases, cataracts, glaucoma, and optic nerve hypoplasia. The results obtained indicate the need to take into account, when selecting optical correction, data of color vision and contrast sensitivity that are of great diagnostic value in a wide range of ophthalmic pathologies.

Of the diagnostic methods, OCT with angiography (OCT-A) of the optic disc showed the highest efficiency. A.M. Coffey et al. [28] strongly recommend the use of OCT-A in optometric practice, since the study provides valuable information in many eye diseases. In particular, in glaucoma, the sensitivity and specificity of the method were 96.7% and 95%, respectively. S.A. Geimer [29] noted 100% specificity of OCT in diagnosing glaucoma, which is especially difficult to detect at an early stage. The author considers the possibility of using OCT for screening glaucoma, but notes the obvious high cost of this type of equipment. According to the author, the development of this technology can lead to the creation of more compact, affordable and easy-to-use equipment. Attention is also drawn to the importance of screening and the role of raising the awareness of ophthalmologists in the effectiveness of early detection of glaucoma is emphasized. According to an Australian study, 23–32% of optometrists use OCT [30].

The publications of foreign researchers also noted an increase in the role of optometrists: the frequency of referral of patients by optometrists to ophthalmologists increased from 39-48% in 1998-1999. up to 72% in 2007–2008 (of which 20% have glaucoma) [9], and 2. 5% of those who turn to an optometrist for a scheduled examination are referred with an identified pathology to an ophthalmologist [8]. Thus, in a significant number of people of any age without any symptoms of eye diseases, during a routine examination, a pathology or its risk is detected, requiring an ophthalmologist’s consultation. The aging of the population and the resulting increase in the frequency of manifestation of eye diseases in the population, long and expensive treatment with serious financial consequences of late detection in the absence of early intervention and treatment of asymptomatic patients are very costly for medical resources, especially provincial ones, and this emphasizes the increasing importance of optometric practice for healthcare systems.

R.O. Lundmark et al. [10] also noted the growing demand for primary ophthalmic care due to the aging of the population, which implies an increased role of optometrists in society, and developed an optimal form for optometrists to refer patients to a medical institution. Preliminary results showed that in Norway, optometrists perform an average of 6 optometry examinations per day and 3.6% of them (about every 28th examination) result in a referral to other medical specialists, mainly ophthalmologists. According to published data, the most common pathologies, accounting for more than half of all registered cases, were cataracts, glaucoma and macular degeneration. There was a high agreement of diagnoses at referral and after additional examination.

In some countries, primary screening of patients for glaucoma at an optometry appointment is standard practice. For example, in the UK back in the 1970s, static semi-automatic perimetry and non-contact tonometry were introduced. Late detection of glaucoma carries potential risks associated with litigation. P.L. Dabasia et al. [31], according to the results of the survey, emphasized the need to introduce special equipment for the detection of glaucoma into optometric practice. An analysis of the frequency of using various diagnostic methods during optometric examination showed that most often (88%) non-contact tonometry was used to determine the level of IOP. The fundus camera was used by 74% of respondents, visualization of the anterior segment, SAP and OCT were performed by 23, 20, 15% of specialists, respectively, and the same number of respondents used gonioscopy. The results of this cross-sectional survey showed that UK optometrists are increasingly investing in new ophthalmic equipment and information technology. At the same time, the costs of acquiring new equipment were largely borne by the owners of the practice.

According to a survey by N. Baker et al. [32], patient satisfaction with optometric reception was 100%. Thus, it can be assumed that British optometrists are able to replace doctors in certain areas of eye care, maintain or improve its quality and patient outcomes. However, most patients still perceive them as spectacle and contact lens fitters.

Limitations of optometric practice in the detection of glaucoma

A number of studies are devoted to identifying the main barriers that prevent early detection of glaucoma in optometric practice. The most frequently cited barriers include: the need for additional training (71%), the patient’s unwillingness to pay for additional tests (61%), low continuity when the patient goes to different institutions (56%), financial unprofitability due to the high cost of equipment (45%), low turnout for follow-up examinations (36%). Thus, optometrists with an appointment time of less than 30 minutes (26%) were statistically significantly more likely to agree that time constraints, equipment levels, personnel and management issues, inadequate record keeping, financial constraints, and lack of continuity of care limit their ability to detect glaucoma in everyday practice. In countries where the profession of an optometrist is well known to the public, the responsibility for detecting glaucoma falls largely on them. According to statistics, from 9Optometrists initiated 0% to 96% of ophthalmological visits with suspected glaucoma. The public perception of the practice of optometry as a retail business with little or no role in healthcare reduces trust in it, which affects the attitude of patients to the need for additional tests and return visits recommended by the optometrist, and lowers the results of ongoing medical care. Identifying additional barriers to glaucoma detection in optometry practice can help inform and support future service reform needed to meet the growing demand for eye care. Consultation with professionals and the study of any obstacles to clinical practice in glaucoma can help in the development of any new treatment regimens for this disease [33].

In an earlier study [34], 88% of the optometrists surveyed reported one or more barriers to glaucoma detection: time constraints that prevent retesting, lack of financial rewards for performing the necessary additional tests, lack of necessary equipment, and low patient awareness of glaucoma.

When asked what could enable optometrists to play a more active role in the detection and treatment of glaucoma, respondents in a Los Angeles survey rated “better equipment” as number one [35].

Thus, it is obvious that, while continuing to perform traditional functions of spectacle and contact correction of visual impairments, as well as rehabilitation of the visually impaired, optometrists now play a much more significant role, approaching practicing physicians [36].

Attempts are constantly being made to optimize the diagnosis of glaucoma in optometric practice. Thus, screening programs for glaucoma are being developed, but it is emphasized that, for example, in the UK, the vast majority of cases of glaucoma are detected by optometrists during routine eye examinations, and the proposed glaucoma screening schemes are still not cost-effective. Screening for glaucoma presents significant challenges as there is no single “simple, safe, accurate and validated screening test” as formulated by the UK National Screening Committee (1998). By this definition, most screening programs do not meet the required standards. In addition, opinions differ regarding the “gold standard” for diagnosing glaucoma. One of the most common methods for detecting and evaluating glaucoma is a comprehensive eye examination of all patients visiting the clinic, regardless of the complaints they present [37].

Clinical guidelines are being developed for the screening, prognosis, diagnosis, treatment, and prevention of glaucoma, and the advantage and importance of additional training for optometrists [30] and the need to improve their qualifications are also emphasized [38]. It is assumed that additional training and adherence to current clinical standards should have a positive impact on the effectiveness of early detection and treatment of glaucoma [39]. There is strong evidence that optometrists additionally trained in the diagnosis of glaucoma can make appropriate diagnostic and management decisions compared to the subspecialty ophthalmologist reference standard.

The researchers highlight the cost-inefficiency associated with the analysis of a large number (36-60%) of false positive cases, i.e. unconfirmed glaucoma diagnoses in patients referred by optometrists. The burden of handling such glaucoma cases in healthcare facilities leads to increased waiting times for new and follow-up appointments and has financial implications for both the hospital and the patient [40]. In this regard, the use of a group of accredited glaucoma optometrists is considered to be more economically advantageous [41]. In addition, developments are underway to introduce joint schemes for the management of such patients by optometrists and ophthalmologists to improve continuity in order to increase diagnostic and financial efficiency when working with glaucoma patients [42]. The need for a joint approach of an optometrist and an ophthalmologist is emphasized, which contributes to the optimal provision of ophthalmic care and related services in ophthalmic pathology, including glaucoma [43]. The development of a questionnaire to help doctors to better detect glaucoma and assess its progression aroused the interest of 88.6% of specialists involved in glaucoma, 99.1% rated it as useful [44].

Thus, in the context of increasing life expectancy of the population and increasing demand for ophthalmological consultations, alternative models of medical care are being explored. In this case, increasing the role of the optometrist could potentially reduce some of the burden relatively quickly and at a lower cost. Notable changes in UK law have expanded the scope of optometric practice. Amendment to the Rules of the General Optical Council Relating to Injury or Disease of the Eye (1999) for the first time allowed local optometrists to decide not to refer patients with an eye disease or anomaly to a doctor unless there was no reason to do so. Parallel to these changes, amendments to drug legislation have made it easier to access them. Consequently, the last decade has seen significant changes in the clinical practice of UK optometrists along with an expansion of existing services. These initiatives have consistently reduced the number of false positives in secondary care. Additional benefits in this case include a reduction in patient waiting times and the number of visits. Thus, despite a limited evidence base and a lack of high quality data, there is evidence that UK optometrists are able to work as substitutes for physicians in certain areas of eye care to improve quality and patient outcomes. Optometrists are generally well received by patients, but further work is needed to establish the cost-effectiveness and feasibility of these services [45].

Conclusion

In recent years, ensuring the availability of medical care, including specialized one, remains one of the leading problems of domestic healthcare, which has emerged against the backdrop of a high incidence of diseases of the organ of vision and a shortage of personnel in the ophthalmological service, which leads to the untimely provision of ophthalmic care to a significant number of those in need. In our country, the incidence rate of the eye and its adnexa is high, its annual increase is observed. At the same time, more than 40% of residents need optical vision correction, the selection of which is carried out by optometrists, their services are extremely in demand [46].

Thus, there is currently great interest in the further professional development of optometry and in increasing the traditional role of optometrists, including advanced training, as an essential prerequisite for expanding the practice. The possibilities of diagnosing glaucoma in optometric practice are limited by the tasks set, the available equipment, the qualifications of the optometrist and his focus on results. Improving the equipment of the optometrist’s office and increasing the level of his qualifications in performing a diagnostic examination will increase the detection of glaucoma. The diagnosis of eye diseases in optometry practice depends on the degree of interaction between the optometrist and the ophthalmologist.

Credits:

Korneeva Alina Vladimirovna – Candidate of Medical Sciences, ophthalmologist at Ophthalmology Elite LLC; 121170, Russia, Moscow, st. Poklonnaya, d. 6; ORCID iD 0000-0002-4435-8114.

Isakov Ivan Nikolaevich – ophthalmologist, head of the ophthalmological department of the State Medical Institution “NGKB No. 1”; 654041, Russia, Novokuznetsk, Bardina Ave., 26A; ORCID iD 0000-0001-5930-8040.

Kuroyedov Alexander Vladimirovich — Doctor of Medical Sciences, Professor of the Department of Ophthalmology of the Russian National Research Medical University named after A.I. N.I. Pirogov of the Ministry of Health of Russia; 117437, Russia, Moscow, st. Ostrovityanova, d. 1; head of the ophthalmological department of the Federal State Institution “TsVKG named after A.I. P.V. Mandryka”; 107014, Russia, Moscow, st. Bolshaya Deer, ow. 8A; ORCID ID 0000-0001-9606-0566.

Onufriychuk Oleg Nikolaevich — Candidate of Medical Sciences, ophthalmologist, FSBI National Medical Research Center for Pediatric Traumatology and Orthopedics. G.I. Turner” of the Ministry of Health of Russia; 197136, Russia, St. Petersburg, st. Lakhtinskaya, 12; ORCID iD 0000-0001-6841-3547.

Contact information: Korneeva Alina Vladimirovna, e-mail: [email protected].

Transparency of financial activities: none of the authors has a financial interest in the presented materials or methods.

There is no conflict of interest.

The article was received on 10/29/2021.

Received after peer review on 11/25/2021.

Accepted for publication on December 20, 2021.

About the authors:

Alina V. Korneeva – C. Sc. (Med.), ophthalmologist of LLC “Ophthalmology Elite”; 6, Poklonnaya str., Moscow, 121170, Russian Federation; ORCID iD 0000-0002-4435-8114.

Ivan N. Isakov — ophthalmologist, Head of the Ophthalmological Department, G.B. Kurbatov Novokuznetsk City Clinical Hospital No. 1; 26A, Bardin av., Novokuznetsk, 654041, Russian Federation; ORCID iD 0000-0001-5930-8040.