Coffs Harbour NSW optometrist Dr Alan Burrow puts his case for patient safety in the debate on initiating glaucoma treatment.
The Royal Australian and New Zealand College of Ophthalmologists’ and the Australian Society of Ophthalmologists’ court challenge to therapeutically endorsed optometrists treating glaucoma autonomously is very disappointing. Apparently, the case is being heard because of concerns about patient safety. Ironically, it is precisely this concern which is shared by both optometrists and ophthalmologists, which has led to the long-standing close collaboration between the professions.
I saw recently two patients within a week, which highlighted the importance of this relationship.
The first case involved a patient who had been treated with Xalatan for glaucoma by an ophthalmologist in a regional centre. Since moving to Coffs Harbour 18 months ago, she had been obtaining prescriptions for Xalatan from her GP without any ophthalmological review.
At the time of consultation I emphasised the importance of regular assessment to ensure efficacy of the treatment. As a result, a battery of glaucoma tests was performed to profile current status. Fortunately, the glaucoma appeared well controlled with, among other parameters, acceptable visual fields and OCT scans with low range intraocular pressures.
The patient requested a further prescription. I advised her that I would be happy to issue one, but felt obliged to mention that under the current regulations I could not endorse it for PBS benefits without a shared-care arrangement with an ophthalmologist.
As she was keen to receive the benefits, an appointment was made for an ophthalmological review. However, the next day she phoned to advise that she had cancelled that appointment as she did not consider it was necessary.
My first reaction was that she would have no choice if she wanted the PBS subsidy. I then realised that she had the alternative of continuing to have prescriptions issued by the GP, which would attract the benefit.
The second case involved a patient whom I had referred to Sydney 10 years ago for management of a right retinal detachment. Despite a number of surgical procedures, there was a significant loss of vision with subsequent development of glaucoma in this eye. The patient had been treated by an ophthalmologist for a number of years with Combigan bid, which resulted in stable pressure in the mid teens. I had examined the patient on numerous occasions during this period and was able to confirm the stability of the pressures.
Six months previously, the ophthalmologist requested that I perform the six-monthly review, with the patient returning to him for the annual review. I was happy to comply with the request.
During the consultation, the patient mentioned that he had been experiencing minor discomfort in the right eye during the previous two weeks but otherwise was symptom free.
He was not aware of any change in vision as a consequence of the limited sight in this eye. There was no obvious ocular injection but there were numerous epithelial bullae with an intraocular pressure measurement of 60 mmHg.
The patient was immediately referred to the ophthalmologist who prescribed Xalatan and Diamox to supplement the Combigan before referring him to a glaucoma specialist.
The following day, the patient contacted me to report that during the previous month he had mistakenly been instilling Chlorsig, prescribed by the GP for his wife, in place of the Combigan, as both bottles were kept in the same cupboard. The pressure was reviewed after reintroducing the Combigan but unfortunately, without the Diamox it remained at an unacceptable level of 49 mmHg. The patient underwent a cyclodiathermy procedure with a positive outcome.
The latter case illustrates the risks associated with treating glaucoma without the ability to measure the intraocular pressure, which would almost certainly have led to this emergency being overlooked.
It also raises the question about whether it is fair to expect GPs who do not have the required glaucoma equipment to have to take the responsibility for prescribing these medications, especially when a well-equipped therapeutically endorsed optometrist is available in an area with infrequent or no ophthalmological service.
While feedback I have received from numerous ophthalmologists is that they see a benefit in working with therapeutically endorsed optometrists, a few apparently consider this an intrusion into the ophthalmologists’ domain. I can appreciate their concern but reports indicate that ophthalmologists who embrace this change benefit from an increase in high quality referrals.
Revolutionary treatments of conditions such as macular degeneration and diabetic retinopathy have placed additional demands on ophthalmologists.
Efficient and cost-effective glaucoma management of the expanding ageing population requires use of therapeutically endorsed optometrists, particularly in regional and rural areas.
Having treated a wide range of pathologies while benefitting from advice, assistance and an excellent working relationship with numerous ophthalmologists, I have no doubt that this is the best assurance of patient safety rather than unnecessary restrictive regulation.