This article first appeared in mivision Issue 154 March 2020. It has been edited and reprinted with the permission of mivision (Toma Publishing).
Written by Inez Hsing and Dr Nick Toalster
It is estimated that approximately 300,000 Australians have glaucoma, however only 50% have been diagnosed.1There is also a large portion of Australians who are glaucoma suspects of some description. Identifying these patients and ensuring they receive time-sensitive and appropriate care can be a challenge.
As of October 2019, there were 5,600 practising optometrists registered with the Optometry Board of Australia (OBA);2 and as of 2016, there were just over 900 accredited ophthalmologists practising in Australia.3
With the rapid growth and aging nature of the Australian population, the incidence of glaucoma is expected to increase. Collaborative care between optometrists and ophthalmologists provides the opportunity to detect disease in a timely manner, ensure appropriate monitoring and review systems are in place and, above all else, prioritise patient-focused care and treatment.
The goal of collaborative care in glaucoma management, above all else, is to optimise patient care and patient outcomes. The Royal Australian and New Zealand College of Ophthalmology (RANZCO) Referral Pathway for Glaucoma Management4 proposed a collaborative model in which low-risk glaucoma suspects can be primarily monitored by optometrists, whereas high-risk glaucoma suspects and early-to-moderate primary open angle glaucoma (POAG) patients should, at the very least, have an initial ophthalmology assessment, and thereafter intermittent reviews with an ophthalmologist depending on their risk of lifetime vision loss. The ophthalmologist can then determine the need for treatment (including a discussion around all possible treatment options, ranging from medication to laser and surgical interventions) as well as assess the patient’s suitability for a collaborative care model. Advanced, acute or unstable glaucoma has been considered “not usually suitable for collaborative care”.5
For collaborative care models to be successful and patient-focused, White and Goldberg6 highlighted the need for “clear lines of communication” (preferably in written form) between optometrists and ophthalmologists. Clinical information, such as review periods, target pressures, treatment plans (both short and long-term), and structural or functional changes which would warrant earlier ophthalmology review, should be included.
While there are certainly advantages to collaborative care models, perceived barriers at the current time include practitioners’ access to diagnostic equipment, variability between different equipment and machines, practitioner skill and knowledge (as well as their desire to participate in collaborative care schemes) and, as mentioned above, ensuring there are reliable and confidential systems in place for communication and transfer of information.
Collaborative care schemes have had success overseas in countries such as Canada, New Zealand, and the United Kingdom.6,7 In the Australian context, the advantages of collaborative care may be even more evident. Collaborative care is particularly well-placed to help tackle the geographic barriers that patients face when accessing specialist care and may help mitigate costs to the patients and the healthcare system as a whole. Collaborative care can potentially improve outcomes for glaucoma patients over the longer-term by breaking down these barriers.
Collaborative care in glaucoma will likely become increasingly common in Australia. The benefits and effectiveness of such models should be assessed periodically, both with respect to economic impact and to determine if there is measurable improvement in patient outcomes such as adherence to reviews and treatment regimes. This will validate the theorised benefit of collaborative care and allow for refinement of policies and guidelines. Not-for-profit organisations like Glaucoma Australia are already encouraging referrals of glaucoma patients into a standardised national database.1
Historically, Glaucoma Australia provides invaluable educational services, support and information for practitioners and patients alike, however the organisation also plays a role in facilitating communication between optometrists and ophthalmologists and could certainly provide a means of monitoring the benefits of collaborative care.
It is also largely recognised that there is maldistribution of eye care practitioners throughout Australia – approximately 83% of ophthalmologists are located in major capital cities,3 and similarly, over three-quarters of optometrists practise in metropolitan areas.8 Patients in rural and regional Australia could, unfortunately, have delayed access to care. Collaborative care in these locations plays a paramount role in ensuring patients are assessed by a suitable practitioner in a timely fashion. Telehealth (or teleglaucoma), in which patient information and imaging is confidentially transferred through the Internet, will almost certainly play a significant role in collaborative care in these situations.
Kassam and colleagues9 reviewed the success of a teleglaucoma system in Western Australia, which allowed for real-time discussion between a regionally located provider, the patient and an ophthalmologist, thereby providing prompt assessment and initiation of treatment for patients who required this. This model or similar may be one to adopt in other regional or remote parts of Australia.
One could hypothesise what would constitute an ideal collaborative glaucoma system. In essence, this would be a system that is easy for patients and healthcare providers to navigate, one that desegregates the public and private systems, and one that reduces the overall cost to society. Additionally, the ideal system would be one that automates the reliable and confidential transfer of data between collaborative partners, and one that has a high fidelity for detecting and treating disease.
Although we have come a long way in glaucoma co-management, and we are already making significant inroads to broadening access to glaucoma care in Australia, there are still many foreseen and unforeseen challenges ahead. Now may be an ideal time for us to take stock of where we are and where we are heading. Data is needed to assess the effectiveness of the various collaborative care programs being implemented, as well as to guide us on where they are of most benefit.
Similarly, there is a need for agreed upon processes that help tackle the barriers, such as effective communication, technology and consent. Perhaps by grappling with these thorny issues we may move closer to that ideal of seamless glaucoma care for all Australians.
Inez Hsing BAppSc (Optom) (Hons), GradCertOcTher, graduated from QUT in 2008 with First Class Honours and a University Medal. She was also awarded the Optometry Australia (QLD & NT Division) Clinical Excellence Award, and completed a Graduate Certificate in Ocular Therapeutics in 2013. Ms Hsing has worked as a clinical optometrist in private ophthalmology practice since 2013 and is currently based at the OKKO Eye Specialist Centre, Brisbane. She is also active in training optometry students as a Clinical Supervisor in the QUT School of Optometry’s primary care clinics. Ms Hsing joined the Glaucoma Australia Optometry Committee in 2017 and is passionate about early detection and education of glaucoma in the general community.
Dr Nick Toalster MBBS (Hons), FRANZCO is an ophthalmologist who sub-specialises in cataract, cornea and glaucoma. He completed degrees in both optometry as well as medicine and surgery, both with honours, at the Queensland University of Technology and University of Queensland, respectively. Dr Toalster trained as an ophthalmologist in Sydney and worked in indigenous communities in the Northern Territory right through to rural New South Wales, as well as in a number of major hospitals in Sydney and Melbourne. He completed subspecialty fellowships in glaucoma, cornea and anterior segment disease.
As both an optometrist and an ophthalmologist Dr Toalster is particularly well placed to understand the emerging field of eye disease co-management, having been involved with glaucoma comanagement programs run through the Royal Victorian Eye & Ear Hospital and helping establish the program at the Royal Brisbane & Women’s Hospital. Dr Toalster is currently based at the OKKO Eye Specialist Centre, Brisbane, and is a Consultant at the Royal Brisbane & Women’s Hospital (RBWH).
1. Glaucoma Australia. Glaucoma Australia launches a bold new referral response intervention [Internet]. New South Wales, 2018 [updated 21 June 2018, cited 29 December 2018]. Available from: www.glaucoma.org.au/articles/ glaucoma-australia-launches-a-bold-new-referral-responseintervention- article/?sch=1178&kw=referral%20pathway.
2. AHPRA Optometry Board of Australia. Optometry Board of Australia: Registrant Data. 31 October 2019. Available from: www.optometryboard.gov.au/About/Statistics.aspx
3. Australian Government Department of Health. Ophthalmology: 2016 Factsheet [Internet]. October 2017. Available from: https://hwd.health.gov.au/webapi/ customer/documents/factsheets/2016/Ophthalmology.pdf
4. RANZCO. Principles for Collaborative Care of Glaucoma Patients [Internet]. Surry Hills (NSW); 2015. Available from: ranzco.edu/wp-content/uploads/2018/11/Guidelines-forcollaborative- care-of-glaucoma-patients-1.pdf
5. RANZCO. RANZCO Referral Pathway for Glaucoma Management [Internet]. 2019. Available from: ranzco.edu/ wp-content/uploads/2019/06/RANZCO-Referral-Pathwayfor- Glaucoma-Management.pdf.
6. White A, Goldberg I. Guidelines for the collaborative care of glaucoma patients and suspects by ophthalmologists and optometrists in Australia. Clinical & Experimental Ophthalmology 2014; 42(2):107-117.
7. Botha VE, Ah-Chan J, Taylor SK, Wang P. Collaborative glaucoma care. Clinical & Experimental Ophthalmology 2015; 43(5):480-483.
8. Australia Optometry. POSITION STATEMENT: The optometry workforce in Australia [Internet]. June 2017. Available from: www.optometry.org.au/wp-content/ uploads/POSITION-STATEMENT-The-Optometry- Workforce-May-2017.pdf
9. Kassam F, Yogesan K, Sogbesan E, Pasquale LR, Damji KF. Teleglaucoma: improving access and efficiency for glaucoma care. Middle East African Journal of Ophthalmology 2013; 20(2): 142-149.