PART 3 OF A 3-PART SERIES
STAFF ABO: OPTOMETRIC STAFF CONTINUING EDUCATION FOR ABO CREDIT

Increasing Your Clinical Value: Opportunities for Optometric Staff to Get Involved with Glaucoma Patients

By Ben Gaddie, O.D., F.A.A.O., and Cassie Tingle, Optometric Technician

Faculty/Editorial Board

Ben Gaddie, O.D., F.A.A.O., and Cassie Tingle, Optometric Technician

Credit Statement

This course is approved for 1 hour of CE credit by the American Board of Opticianry. Course approval number SJMH274-1.

SPONSORSHIP

This course is supported by an independent educational grant from Allergan, Inc.

DISCLAIMER

The opinions expressed in this supplement to Review of Optometry do not necessarily reflect the views, or imply endorsement, of the editor or publisher. Copyright 2012, Review of Optometry®. All rights reserved.

In the United States, more than 120,000 people are blind from glaucoma, accounting for 9% to 12% of all cases of blindness.¹ Another two million do not know they have the disease.² From a public health standpoint, despite our collective best interests, we have not improved significantly enough in this area. Over the last 40 years, optometrists have expanded their scope of practice through legislative authority to include the treatment of glaucoma in almost every state in the country. With the baby boomer generation just reaching the age most likely to develop glaucoma—65 and older—we are going to have our hands full not only treating more glaucoma patients, but also sorting out which patients simply have ocular hypertension or suspicious optic nerves.

An optometric staff person's data collection is imperative to assisting the optometrist in providing the patient with excellent medical care. The clinical staff can do many things to ensure that both doctor and patients are receiving the information needed to develop a treatment plan and set the stage for treatment compliance. The technician's education about glaucoma is an important part in assisting the doctor. Knowledge about ocular disease allows them to be more involved in patient care. Your practice may opt to develop a standard evaluation for the diagnosis and treatment of glaucoma so that both the doctors and the technicians know what to expect in terms of testing protocol.

Opportunities to Grow Your Practice

Optometrists and their staff should make a concerted effort to develop an organized standard evaluation for patients suspicious of glaucoma. For patients who have been diagnosed, practices will likely be highly rewarded in terms of patient satisfaction and practice growth. Your dedication to glaucoma, embracement of new technology and presence at the forefront of care can benefit your patients and practice.

A team-coordinated approach to glaucoma evaluations can help you increase your productivity by creating a streamlined system that includes an order from the doctor for testing, proper scheduling and efficient administration of the diagnostic tests. In this model, everyone should be involved in the process to ensure efficient patient flow. The front desk should recognize that the patient is there for diagnostic testing and route the chart to the appropriate pre testing technicians. The scribe and doctor should be aware of who is on the imaging and visual field instruments in case you have a patient being seen that day who may need additional diagnostic testing on the spot. In addition, providing patient education allows delivery of better patient care, thereby increasing your role as optometric technicians in the treatment of glaucoma.

The ABCs of Glaucoma

Glaucoma refers to a group of eye conditions that lead to damage of the optic nerve. In most cases, damage to this structure is caused by increased pressure (intraocular pressure, or IOP) in the eye. There are many different types of glaucoma, but the four main types are: open-angle, angle-closure, congenital and secondary.

Open-angle glaucoma. This type of glaucoma is chronic and most common, yet the cause is unknown. An increase in IOP occurs slowly over time and damages the optic nerve. Most people do not have symptoms; once noticeable vision loss occurs, the damage is already significant.

Low-tension glaucoma. Low-tension glaucoma is technically an open-angle but without elevated IOP. Approximately 50% of all open-angle glaucoma is not associated with elevated IOP.

Angle-closure glaucoma. This acute type of glaucoma is an emergency and occurs when the exit of the aqueous humor (fluid) is suddenly blocked, which causes a quick, severe and painful rise in IOP. Symptoms (e.g., sudden, severe pain in one eye; severe headache or brow pain; decreased or cloudy vision; nausea and vomiting; rainbow-like halos around lights; red eye) may come and go at first, or become steadily worse.

Congenital glaucoma. Seen in babies, this type of glaucoma often runs in families and is caused by abnormal eye development. Symptoms (e.g., cloudiness of the cornea; enlargement of one or both eyes; red eye; sensitivity to light) are usually noticed when the child is a few months old.

Secondary glaucoma. This type of glaucoma is caused by drugs such as corticosteroids, eye diseases such as uveitis, systemic diseases and trauma.

Risk Factors

Glaucoma is an asymptomatic disease—except end-stage cases and acute-angle closure patients. Therefore, a patient would likely have no idea they have or are at risk for the disease. Obtaining a complete and accurate medical history is the first step, even in established patients who have not been previously diagnosed with glaucoma. Patients are often not aware of the risk factors for glaucoma and the technician should ask them the right questions to extract as much risk related information as possible. Optometric staff should ask patients about the following glaucoma risk factors:

• Hypertension
• Sleep apnea
• High myopia
• A family history of glaucoma
• African American race
• Hispanic/Latino ethnicity
• A history of high IOP
• Migraine
• Suspicious optic discs

It is also important to note whether the patient has ever been a known steroid responder (IOP elevation after several weeks of topical steroid use), as this raises the risk of converting to glaucoma later in life. If a patient has a family history of glaucoma, it is useful to gather information by asking how they are related and if the family member is, or was, on prescription eye drops or had surgery for glaucoma.

During the review of symptoms, optometric staff should note several key areas that are important for the doctor to be aware of during their evaluation. If a patient is on blood pressure medicine, this may indicate to the doctor that the patient has poor cardiovascular status that could affect blood flow to the eye. Beta-blockers are a common class of anti-hypertensive medication that can reduce blood pressure and possible nocturnal blood flow to the eye. In addition, they can actually lower IOP, resulting in false estimations of glaucoma mediation efficacy. If a patient has bad allergies and is on a chronic nasally inhaled steroid, the doctor will want to make sure the IOP is stable and not resulting in glaucoma. The same holds true for dermatological patients using facial steroids. Other systemic diseases such as diabetes, thyroid and sleep apnea may have some impact on glaucoma, and the optometrist should have knowledge of this information.

Certain protocols for new patients with glaucoma coming into the office for the first time should be followed. For instance, the optometric staff should attempt to contact the patient prior to the initial appointment to request their previous medical records and ask them to bring their glaucoma eye drops to the appointment. Another important part of a glaucoma evaluation is documenting all previous treatment plans, negative side effects to glaucoma eye drops, if applicable, and patient compliance with glaucoma treatment.

Optometric Staff's Role in Pretesting

The optometric staff is vital in communicating effectively with the glaucoma patient before the doctor ever comes into the room. Reviewing the patient's medical history with them is the first step in recognizing whether they are at an increased risk for glaucoma. Staff should be trained to look for risk factors such as family history of glaucoma, sleep apnea or hypertension and document the risk factors for the doctor.

Optometric staff should routinely inquire about the patient's glaucoma eye drops. As with any drug, these medications can cause side effects that patients will be aware of and occasionally side effects the patient does not notice. The staff should be trained to recognize the external side effects, which can include eye redness, skin irritation around the eyes, eye lash growth, burning, dizziness, darkening of eye color and deepening of the eyelid sulcus.

If the patient is having side effects, it should be documented in the chart and brought to the doctor's attention. At that point, the doctor and patient can discuss the ramifications of the side effects and alternative treatment options.

It is important to ask patients who are on glaucoma eye drops if they need refills at each visit. Electronic prescribing has made refilling prescriptions much easier. Always ask the patient if their insurance allows for 90-day prescriptions through mail-order pharmacies, because this option often has a less expensive co-payment amount. If the patient is unsure, encourage them to find out. It is also helpful to be aware of patient assistance drug plans, which are available for low-income patients and those without medical insurance. Patients' compliance is often dependent on whether they can afford their eye drops.

The technician should also find out if the patient is using name brand or generic eye drops because sometimes pharmacies will dispense generic eye drops to patients without consulting the prescribing doctor. If the patient doesn't bring their drops with them to the visit, you will have no idea if the patient who has been prescribed a name brand eye drop is really on the generic solution. Any time a patient begins a new eye drop—even when going from name brand to generic—a pressure check is required to make sure the drops are effective in lowering the IOP.

Tools for Glaucoma Evaluations

A glaucoma evaluation usually includes several tests that the tech nician performs before the patient sees the doctor. A typical yearly glaucoma evaluation includes pressure readings, visual fields, gonioscopy, fundus photos and an OCT. An initial glaucoma evaluation also includes pachymetry.

The technician can have a varying scope regarding the measurement of IOP. There are several instruments where technicians may be involved in one of the most important measurements. One such instrument is an ocular response analyzer, which gives not only non-contact IOP, but also a measure of corneal hysteresis (CH).

CH has been strongly correlated with weakened corneal biomechanical properties, which, in turn, has been associated with a greater risk of developing glaucoma or having progressive glaucoma.

Tonometers are also useful for measuring IOP and approximating the pulsatile ocular blood flow. Some handheld tonometers require no anesthesia. They are very easy to use and patients love them. In fact, you can usually get a reading on even the most apprehensive patients using a handheld tonometer.

Visual fields and optical coherence tomography (OCT) are also generally performed on a yearly basis. At times, the doctor will order the tests more frequently, depending on the patient's severity of glaucoma or level of compliance with the tests. Visual fields provide invaluable information on the health and condition of the optic nerve. The patient sits at an instrument with one eye covered. With the other eye fixated on a target, the patient responds when they see stimuli by pressing a button. This visual field test can be very difficult for some people. The technician should encourage the patient to stay fixated on the target so that the test is accurate. The patient should be sitting as comfortably as possible because the test can last several minutes. The patient can also be advised that the test can be paused if they need to take a short break, and the technician should suggest a break if the patient appears to be getting tired.

Once the visual field is completed, a guided progression analysis (GPA) should be printed for the doctor if it is available. This analyzes several years of data to assist the doctor in determining whether the patient's glaucoma is stable or if there has been a loss of vision in their visual field. If the patient has high fixation losses, high false positives or high false negatives, the GPA will not be available.

An OCT is an instrument that technicians can use to quickly scan different structures in the patient's eye, such as the optic nerve and macula. The retinal nerve fiber layer (RNFL) is measured and the readings are used to measure any progress in glaucoma. The macula's ganglion cell layers are also now being imaged by most spectral domain OCTs (SD-OCTs). This can be an even earlier area for evidence of glaucoma conversion—some speculate it is better than the RNFL.

Pachymetry is a simple test that is important to the differential diagnosis of glaucoma versus ocular hypertension. It measures corneal thickness, which affects the accuracy of IOP readings. All patients being evaluated for glaucoma for the first time should have pachymetry performed. Normal pachymetry readings are approximately 550 µm to 590 µm. A cornea that is thinner than average is considered below 530 µm. A cornea that is thicker than average is 600 µm or more. Corneal thickness will help determine how a patient's glaucoma is managed. If someone has both glaucoma and thin corneas, then the glaucoma is more likely to progress to further vision loss.

Time to See the Doctor

Once the optometric staff has completed the glaucoma tests, the patient is ready to see the doctor. At this time, the staff can assist with further testing. Common tests the doctor will perform are Gold-mann tonometry, slit lamp examination, gonioscopy and dilation. It is helpful for the technician to stay with the doctor to continue the flow of the exam. The technician can instill eye drops, prepare the gonio lens and assist the doctor with each test. You may opt to assign a scribe to each doctor to assist in using your time with the patient most effectively.

Goldmann tonometry is the most accurate method in checking IOPs. The technician will instill a numbing eye drop and fluorescein dye. The slit lamp examination is how the doctor can assess external side effects to glaucoma eye drops. The slit lamp examination is also how the doctor determines if a patient has narrow angles, putting the patient at risk for narrow-angle glaucoma. Gonioscopy is performed on all initial glaucoma evaluations and periodically thereafter. The gonio lens allows the doctor to view the angle of the eye through a mirror, which enables the doctor to see the structures in the eye responsible for the normal fluid flow and pressure regulation. Some types of glaucoma, such as pigmentary and pseudoexfoliation glaucomas, are easier to see by their gonioscopic findings.

Treatment

Glaucoma treatment options include eye drops, laser procedures and filtering surgery. Typically, eye drops are the first treatment option, commonly prescribed once or twice daily. Quarterly pressure checks are ordered for patients on glaucoma eye drops to monitor IOPs. The time of day can affect the pressure readings due to normal fluctuations; periodically, the doctor may request that the patient come to clinic in the morning or afternoon to document any fluctuations.

Laser procedures for the treatment of glaucoma include selective laser trabeculoplasty (SLT), argon laser trabeculo-plasty (ALT) or laser peripheral iridotomy (LPI). The doctor will recommend a laser procedure to lower pressures when medication is not sufficient. SLT and ALT are used for the treatment of primary open-angle glaucoma. The technician can assist in the perioperative time frame by performing the physical and medical history, informed consent, pre-op testing and ultimately helping the doctor in the laser room. Postoperative medication instillation and blood pressure monitoring help facilitate patient flow for the practice.

Optometric Staff Recaps

When a patient is diagnosed with glaucoma, or as a glaucoma suspect, they will need education on the etiology, diagnosis and prognosis of the disease. The staff takes on the role of ensuring that the patient has a clear understanding of treatment options recommended by the doctor. Educational videos are often an effective way to help patients understand what the disease is and how it is managed. By educating the patient, the technician allows both the patient and doctor more time to make decisions regarding the treatment plan. Because glaucoma does not have any symptoms, it can be difficult for patients to understand the disease. The clinical staff assists the doctor in explaining glaucoma in easy to understand terms.

Final Thoughts

Your practice may choose to put a system in place that informs patients when they have missed an appointment for glaucoma checks. Monitoring patients on a doctor-prescribed interval is vital to the treatment and prevention of glaucoma-related vision loss. IOP needs to be monitored on a regular basis. Optometric staff can make personal phone calls to patients to schedule another appointment if one has been missed. Many times, patients are grateful for the reminder call. Sometimes they simply need to be reminded that their eye health is a great concern to their doctor. It is also effective to send a reminder letter to patients who miss an appointment. This also provides written documentation that the office has reached out to the patient. Sometimes, certified letters are required if patients routinely miss their follow-up appointments. In conclusion, optometric staff play an integral role in glaucoma patient care. Having well-trained and experienced staff can make the difference in patient confidence and ultimately more referrals. Having the ability to explain to the patients why the tests are being performed can ease their anxiety and create rapport that is necessary when patients are entrusting their eyesight to your team. With the right attention and motivation, glaucoma care will rapidly expand in your office and become one of the most gratifying conditions your office manages.

Dr. Gaddie is the immediate past president of the Kentucky Optometric Association and president of the Optometric Glaucoma Society. He is the CEO of Gaddie Eye Centers in Louisville, Ky.

Ms. Tingle is the lead optometric technician at Gaddie Eye Centers' headquarters location.

References

1. Friedman DS, Wolfs RC, O'Colmain BJ, et al; Eye Diseases Prevalence Research Group. Prevalence of open-angle glaucoma among adults in the United States. Arch Ophthalmol. 2004 Apr;122(4):532-8.
2. Prevent Blindness America, National Eye Institute. Vision problems in the U.S.: prevalence of adult vision impairment and age-related eye disease in America. Chicago: Prevent Blindness America; 2008.

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