Improvements in the Detection and Management of Glaucoma
Submitting InstitutionCity University, London
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Ophthalmology and Optometry, Public Health and Health Services
Summary of the impact
Glaucoma affects around 2% of people over 40 years of age and almost 10%
of those over 75. There are more than one million glaucoma-related
outpatient visits to hospital eye services annually. Once lost through
glaucoma, sight cannot be restored. Therefore early detection (mainly by
optometrists) and appropriate management of the condition are crucial to
maintaining a sighted lifetime. Uncertainty and variation exist in
clinical practice and service delivery. Research undertaken by academic
staff at City University London has led to:
- contributions to the development of computer software used in hospital
clinics globally to assess glaucoma;
- changes in the management by the National Health Service of one group
of patients (ocular hypertensives) at risk of glaucoma;
- unique films, developed at City, of patients `driving' with vision
loss resulting from glaucoma being used by the BBC and the International
Glaucoma Association to increase disease awareness;
- curricula for professional qualifications in glaucoma (based on a
competency framework developed by City) becoming the national standard
In addition, City research on the scope of therapeutic practice by
optometrists and the development of clinical management guidelines (CMGs)
strongly influenced the decision to extend independent prescribing to
optometrists. CMGs developed at City were incorporated into the Map of
Medicine and other national ophthalmology primary care pathways. Research
on a repeat-measurement-enhanced glaucoma scheme generated a National
Institute for Health and Care Excellence (NICE) Quality, Innovation,
Productivity and Prevention (QIPP) Case Study and informed Joint College
Commissioning Guidance on Glaucoma and Local Optical Committee Support
Unit (LOCSU) schemes. City's Standardised Patient research, where actors
play the role of patients to collect evidence on actual clinical practice,
is unique in optometric research and has been referred to by experts and
relied upon in the defence of optometrists' actions in several
clinico-legal cases before the General Optical Council.
Glaucoma detection: Glaucoma detection is often achieved by
testing the patient's field of vision (visual field). Work related to
visual field testing led by Professor David Crabb (dating back to 1996 but
at City since 2005) demonstrated the limitations of standard techniques
and led to new computer-based methods of testing. The research progressed
to link such measurements taken in the clinic with the patient's actual
function when performing everyday tasks. The study described in 
investigated eye movements in glaucomatous patients when viewing driving
scenes in a hazard perception test (HPT). The work showed that
characteristics of eye movement patterns in patients with bilateral
glaucoma can differ significantly from age-matched controls when viewing a
Glaucoma: monitoring and treatment. Crabb's work with the
University of Aberdeen  to determine optimal surveillance regimes for
monitoring ocular hypertensives (patients at risk of glaucoma) identified
and validated glaucoma risk prediction models and developed models to
determine optimal surveillance pathways. The research demonstrated that
for confirmed ocular hypertension there is no clear benefit from intensive
monitoring for development of glaucoma and that biennial monitoring may be
the best option.
Glaucoma: service delivery. Glaucoma-related activity within the
Hospital Eye Service is a major and increasing NHS burden. Over 90% of
referrals for suspect glaucoma originate from High Street (community)
optometrists following routine sight tests. Edgar (at City since 1977, now
Professor) and Parkins (Bexley Care Trust) collaborated on a project which
assessed the effectiveness of a new referral scheme involving community
optometrists . It provides incentives for optometrists to improve the
quality of referrals for suspect glaucoma by repeat testing with standard
screening tests before taking the final decision whether to refer. Repeat
testing resulted in 76% of patients in the scheme not being referred from
community optometrists to the hospital glaucoma clinics, leading to
significant cost savings to the NHS.
Standardised Patients (SPs): SPs are actors who, unknown to the
clinician examining them, play the role of patients and report on the
clinicians' practice. SPs are widely used in medicine where they are
considered the reference standard for measuring quality of clinical
practice, but had not previously been used in optometry research. Since
2006, Edgar (with Shah and Evans of the Institute of Optometry) and
Lawrenson (at City since 1994, now Professor) have co-led on SP-based
studies which provided a unique picture of actual optometric practice [3,
4]. They showed that SP encounters are an effective way of measuring
clinical care within optometry and should be considered for further
comparative measurements of quality of care; and that there are
differences between the "real-world" picture of optometric clinical
practice and the College of Optometrists published guidelines for
professional conduct. The research also identified notable cases of
under-recording of results. They made recommendations on the focus of
future optometric continuing education.
Competency Frameworks: Lawrenson has significant research
expertise in developing competency frameworks in healthcare. Following
publication of the NICE clinical guidelines on glaucoma in 2009, Lawrenson
and Edgar, using a consensus methodology consisting of a modified Delphi
technique, convened a multidisciplinary team to develop a competency
framework for optometrists with a specialist interest in glaucoma to
provide a basis for training and accreditation. This will help to shape
the development of a specialty curriculum and could be adapted for other
healthcare professionals. 
Therapeutic Practice: Noting that changes in medicines legislation
in the UK have broadened the opportunities for optometrists to use and
supply therapeutic drugs, research led by Lawrenson defined, for the first
time, the scope of therapeutic practice by community optometrists and
elicited their views on an extended prescribing role . The survey of
the College of Optometrists covered four areas: mode of practice,
proximity and relationship to other providers of eye care, scope of
current therapeutic practice and future plans regarding prescriber
training. The research showed that significant numbers of community
optometrists are managing a range of common ocular conditions using a
limited formulary. Enabling optometrists to train as independent
prescribers will further develop this role, allow greater use of their
skills and provide patients with quicker access to medicines.
References to the research
1. Crabb D.P., Smith N.D., Rauscher F.G., Chisholm C.M., Barbur J.L.,
Edgar D.F. & Garway-Heath D.F. (2010). Exploring eye movements in
patients with glaucoma when viewing a driving scene. PLoS One,
5(3) e9710 10.1371/journal.pone.0009710
2. Parkins D.J. & Edgar D.F. (2011). Comparison of the effectiveness
of two enhanced glaucoma referral schemes. Ophthal. Physiol. Opt.,
31(4), 343-352 10.1111/j.1475-1313.2011.00853.x
3. Shah, R, Edgar, DF, Spry, PG, Harper, RA, Kotecha, A, Rughani, S,
Evans, BJ. (2009). Glaucoma detection: the content of optometric eye
examinations for a presbyopic patient of African racial descent. Br.
J. Ophthalmol., 93(4), 492-496. doi:10.1136/bjo.2008.145623
4. Shah R., Edgar D.F., Harle D.E., Weddell L., Austen D.P., Burghardt D.
& Evans B.J.W. (2009). The content of optometric eye examinations for
a presbyopic patient presenting with symptoms of flashing lights, Ophthal.
Physiol. Opt., 29(2), 105-126 10.1111/j.1475-1313.2008.00613.x
5. Myint J., Edgar D.F., Kotecha A., Crabb D.P. & Lawrenson J.G.
(2010). Development of a competency framework for optometrists with a
specialist interest in glaucoma, Eye 2010(24), 1509-1514 10.1038/eye.2010.62
6. Needle J.J., Petchey R. & Lawrenson J.G. (2008). A survey of the
scope of therapeutic practice by UK optometrists and their attitudes to an
extended prescribing role. Ophthal. Physiol. Opt. 28(3), 193-203 10.1111/j.1475-1313.2008.00551.x
Key Research Grant
NIHR Health Technology Assessment (HTA) Programme Project www.hta.ac.uk/project/1757.asp.
Crabb Co-Investigator with Dr J Burr (University of Aberdeen) Title:
Optimal Surveillance Regimes for Individuals with Ocular Hypertension
(OHT): Modelling and economic evaluation.
The work is all published in double-blind peer-reviewed journals and we
believe that appropriate scientific rigour is demonstrated concerning
design, method, execution and analysis.
Details of the impact
Glaucoma detection: Research on visual fields has led to the
jointly-developed Moorfields Motion Displacement Test (MDT) (www.moorfieldsmdt.co.uk),
a novel form of visual fields test. The MDT was winner of the Medical
Research Council translational research innovation award (2008) and
published as one of the Big Ideas for the Future by Research
Councils UK in 2011 . The recent NICE guidelines for glaucoma made an
important recommendation for research to improve patient care in the
future, including a call to establish the clinical-effectiveness and
cost-effectiveness of using different monitoring intervals to detect
disease worsening or stability in patients diagnosed with the condition.
Crabb is the principal investigator on a research project tasked with
answering this research question and funded by the NHS National Institute
for Health Research (NIHR) Health Services and Delivery Research (2011 to
Glaucoma: monitoring and treatment. People with glaucoma need
lifelong monitoring to detect any deterioration of vision. Computer
software for improving assessment of visual field loss (PROGRESSOR visual
field software [Medisoft Ltd.]) and monitoring optic nerve head changes
(Moorfields Regression Analysis for the Heidelberg Retina Tomograph
[Heidelberg Engineering Ltd.]) has been adopted in glaucoma clinics
globally. Use of this software improves the ability to identify correctly
changes in the disease that may require changes in treatment regimes.
Crabb's work with Burr (Aberdeen) has resulted in changes in the way
patients at risk of glaucoma can be managed by the NHS . The videos of
eye movements during driving with visual field loss have been used by the
BBC and the International Glaucoma Association  for patient awareness.
Glaucoma: service delivery. Glaucoma is a high-volume and
resource-demanding disease where significant efficiencies can be made by
decentralising care and making greater use of the skills of community eye
care providers. In repeat measurement schemes, community optometrists
repeat key tests on a second visit before deciding whether to refer
patients as glaucoma suspects. Research by Edgar and Parkins on a
repeat-measurement-enhanced glaucoma scheme in Bexley formed the basis for
a Case Study published in late 2011 as a NICE QIPP in NHS Evidence .
The case study reported a 62% saving against HES (Hospital Episode
Statistics) tariff (equating to £15k per million people). As a result of
this research, NHS London awarded a grant to NHS South East London as part
of its Continuing Professional and Personal Development funding stream.
This funding has led to the extension and integration of repeat
measurement schemes across every Clinical Commissioning Group area in SE
London. The research also informed the 2013 Joint College Commissioning
Guidance on Glaucoma . The Parkins and Edgar research paper is the only
peer-reviewed publication quoted in the LOCSU repeat-measurement-enhanced
service pathway for glaucoma and ocular hypertension . This pathway has
been adopted in enhanced schemes across England. Repeat measures schemes
lead to more care provided in the community and save NHS resources.
Standardised Patients (SPs): In clinico-legal cases, an
optometrist's actions can be successfully defended if it can be shown that
the care provided is supported by the actions of a significant body of
reasonably competent optometrists. The City evidence-based investigations
into the content of an optometric eye examination have been central to the
defence of optometrists' actions in a several recent clinico-legal cases.
The SP research papers have been identified by expert witnesses and legal
teams as providing unique evidence supporting what "reasonably competent
optometrists" are likely to do in some real-life optometric practice
situations . Published clinical guidelines, which are also often used
as evidence in clinico-legal cases, do not always fully reflect actual
clinical practice. Our research papers have also been quoted in the record
audit guidance section for Quality in Optometry, Level 1, an NHS England
approved toolkit .
Competency frameworks: Lawrenson has significant expertise in
developing competency frameworks in healthcare and has worked with NICE to
produce frameworks for medical and non-medical prescribers . The
guideline recommends that any healthcare professionals involved in the
diagnosis and monitoring of glaucoma have a specialist qualification.
Following its publication, a team led by Lawrenson was commissioned by the
College of Optometrists to develop curricula for professional
qualifications in glaucoma based on the competency framework developed by
City . These qualifications have become the national standard for
optometrists working in this specialty  and ensure optometrists have
the appropriate level of diagnostic and management skills.
Therapeutic practice: Lawrenson, as a member of the Cochrane Eyes
and Vision Group, has used evidence synthesis and critical appraisal
techniques to develop Clinical Management Guidelines for primary eye care
. They were adopted in 2008 by the College of Optometrists to support
therapeutic prescribers and form the basis of national pathways for
referral and management of eye disease. Research on the scope of
therapeutic practice by Lawrenson and the development of evidence-based
clinical management guidelines at City strongly influenced the decision by
the Commission for Human Medicines to extend independent prescribing
responsibilities to optometrists . This policy change has
substantially increased the benefits that optometrists offer to patients
in terms of their quality of care and patient experience. Independent
prescribing has had particular impact on the management of glaucoma .
Although originally written for optometrist prescribers, the Clinical
Management Guidelines developed at City have been incorporated into the
Map of Medicine and other national ophthalmology primary care pathways
. The Guidelines ensure that management and referral of eye disease by
optometrists and general practitioners is appropriate and informed by best
Sources to corroborate the impact
- RCUK Big Ideas for the Future Report 2011 [Internet]. [cited 2012 Mar
16]. Available from: www.rcuk.ac.uk/documents/publications/BigIdeasfortheFuturereport.pdf.
- NIHR Health Technology Assessment (HTA) Programme Project www.hta.ac.uk/project/1757.asp
Co-Investigator with Dr J. Burr (University of Aberdeen) Title: Optimal
Surveillance Regimes for Individuals with Ocular Hypertension (OHT):
Modelling and economic evaluation.
- International Glaucoma Association 2011 [Internet] Available from:
- NHS Evidence — QIPP (Quality, Innovation, Productivity and
Prevention). Title: Avoiding unnecessary referral for glaucoma: use of a
repeat measurement scheme. QIPP — NHS Evidence, 22 December 2011 —
Publisher: NHS South East London — Publication type: Quality and
Productivity Example. http://arms.evidence.nhs.uk/resources/qipp/617475/attachment.
- Commissioning better eye care: clinical commissioning guidance from
The College of Optometrists and The Royal College of Ophthalmologists.
Glaucoma. Version 1. Published 14th February 2013.
- Glaucoma repeat readings & OHT monitoring enhanced service
pathway. Issued by Local Optical Committee Support Unit. May 2009
[Revised June 2012]
- Corroborative statements can be provided by the Director of Legal
Services and/or the Chairman, Association of Optometrists. Address:
Association of Optometrists, 2 Woodbridge Street, London, EC1R 0DG.
- Corroborative statement can be provided by the Clinical Adviser to the
Legal Services Team, Board Member, Association of Optometrists.
- NICE 2012. A single competency framework for all prescribers.
- Corroborative statement can be provided by the Director of Policy and
Strategy, College of Optometrists.
- College of Optometrists. Available from: www.college-optometrists.org/en/professional-standards/clinical_management_guidelines/index.cfm.
- Online minutes of the Commission for Human Medicines. June 2007.
- National Prescribing Centre. Optometrist independent prescribing in a
one-stop optometry glaucoma assessment clinic.
- NICE Clinical Knowledge Summaries. http://cks.nice.org.uk/glaucoma#!scenariobasis.