John G. Flanagan PhD, MCOptom , FAAO Professor, School of Optometry, University of Waterloo

1. OPTOMETRIC LEADERS’ FORUM Glaucoma Collaboration: CGS Guidelines John G. Flanagan PhD, MCOptom, FAAO Professor, School of Optometry, University of Waterloo Professor, Dept of Ophthalmol & Vis Sci, University of Toronto Director, The Toronto Hospital Glaucoma Research UnitSenior Scientist, The Toronto Western Research Institute and Bernard B. Fresco OD, MSc, FAAO

2. The Task and the Timeline • Approached by CAO in March 2010 to work with Canadian Glaucoma Society’s Interprofessional Collaboration Committee in Glaucoma Care • With Dr B. Fresco • First meeting at ARVO in May 2010 • Desire to reach concensus • Co-management not an option • CGS Draft Guidelines to be used as starting point • Regular conference calls and revisions by e-mail • Unfinished draft presented to CGS meeting (COS, Quebec City) July 2010 • Draft Guideline August 2010 • Many of the previous gains overturned following CGS meeting • Presented to COS for input • CAO informed that consensus unlikely • CGS hoping for consensus following input from COS and CAO

3. Scope and Principles • INTRODUCTION: Paragraph 3 added to Aug 17th draft “…… we are not differentiating between comprehensive ophthalmologists and ophthalmologists with glaucoma subspecialty training.” • SCOPE: “…the goal of better defining models of care for patients with glaucoma and glaucoma suspects, with the ultimate goal of increasing accessibility and yet maintaining quality of care provided to these patients.” • PREREQUISITES FOR MANAGING GLAUCOMA……. • Minimum clinical standards for all • Good communication between all health professionals • “It should be absolutely clear to patients who is the eye care professional responsible for his/her care at every stage of the disease.”

4. Scope and Principals • DEFINITION of PATIENT GROUPS • Early glaucoma patient stable: “Stability is defined as IOP within target pressure and no visual field or optic disc deterioration in the last 3 years. Any recently identified patient with glaucoma would be considered unstable until stability is proved with long-term follow-up.” • Cannot be stable unless proven over 3 year period • “A general principal within these Guidelines is that it is advisable for the surgeon most likely to be involved in the tertiary care of a given patient, should it be required in the patient’s future management, evaluate the patient early in the management of the disease. This may not always be possible but provides the reasoning behind several of the listed recommendations.”

5. 5. RECOMMENDATIONS • Glaucoma suspect with low/moderate risk: Glaucoma suspects initially assessed by the attending optometrist and judged to be of low to moderate risk do not require a referral to an ophthalmologist. • Glaucoma suspect – high risk: “As a general rule, high risk glaucoma suspects can be followed and monitored by optometrists.” “If a decision to start ocular hypotensive therapy is contemplated, it is strongly recommended that the patient be referred to an ophthalmologist for an opinion. If the ophthalmologist agrees with initiation of therapy, a clearly outlined treatment plan and targets should be communicated back to the optometrist. These patients can generally be monitored by optometrists, with periodic referrals to the ophthalmologist as needed.” Looks like co-management, feels like co-management…….. but THERE IS NO CO-MANAGEMENT

6. 5. RECOMMENDATIONS • Glaucoma suspect – high risk: “In general terms, referrals to the ophthalmologist should be considered if: i. augmentation of ocular hypotensive therapy is contemplated. ii. progression is suspected in disc and/or visual field. iii. there is uncertainty in the clinical findings.” Our Recommendation for 5b: High risk glaucoma suspects can be followed, treated and monitored by optometrists.

7. 5. RECOMMENDATIONS • Stable early glaucoma patient. “Once an optometrist makes a diagnosis of early glaucoma, a referral to an ophthalmologist is strongly recommended.” “Once stable, the patient can be returned to the optometrist for monitoring and management, but it is recommended that the patient be re-assessed by an ophthalmologist at regular intervals, usually every 3-4 years, so the ophthalmologist can maintain some contact with the patient, in case he/she requires more aggressive laser or surgical therapy in the future.” Remember STABLE takes at least 3 years! Our Recommendation for 5c: Replace 1st paragraph with: “Optometrists can diagnose early glaucoma and initiate treatment.”

8. Progression in Glaucoma: EMGT Treated patients, EMGT MD (dB) 0 ~0.05 dB/yr 2X normal aging rate -5 -10 Rate of progression range -15 ~0.35 dB/yr 7X normal aging rate ~2.5 dB/yr 50X normal aging rate -20 -25 Age (years) 50 55 60 65 70 75 80 85 90 95 100

9. 5. RECOMMENDATIONS • Stable moderate / advanced patient. “Patients with stable moderate or advanced disease should be primarily managed by an ophthalmologist, unless transportation barriers or non-availability of an ophthalmologist are a significant issue.” Our Recommendation for 5d: • Stable moderate glaucoma. “Patients with stable moderate disease can be monitored and treated by an optometrist…...” “Any sign of the unstable disease would initiate a referral (Section 5.f).” Add 5e) Stable advanced glaucoma patient. “Patients with advanced disease may be managed by an optometrist but periodic consultation with an ophthalmologist would be advisable given the higher potential need for laser or surgical care in these cases.”

10. 5. RECOMMENDATIONS • Any unstable glaucoma patient. “Patients should be considered unstable if they have shown signs of progressive glaucomatous damage or if they are not meeting the previously specified target IOP.” i. IOP instability - If a patient on anti-glaucoma treatment is being managed by an optometrist and the IOP is greater than the established target IOP, it is recommended that the optometrist refer the patient to an ophthalmologist. The optometrist should communicate the medications used and the resulting IOP………. Our Recommendation: If a patient on anti-glaucoma treatment/s is being managed by an optometrist and the IOP is greater than the established target IOP, it is recommended that the optometrist refer the patient (to a glaucoma specialist). The optometrist should communicate the medications used and the resulting IOP.

11. 5. RECOMMENDATIONS • Any unstable glaucoma patient. ii. Visual field criterion - If a patient on anti-glaucoma treatment is being managed by an optometrist and there is a repeatable, clinically significant change in the threshold visual field, it is recommended that the optometrist refer the patient to an ophthalmologist. The optometrist should communicate all pertinent test results and clinical findings. Our Recommendation: If a patient on anti-glaucoma treatment/s is being managed by an optometrist and there is a repeatable, clinically significant change in the threshold visual field, it is recommended that the optometrist refer the patient (to a glaucoma specialist). The optometrist should communicate the medications used,all pertinent test results and clinical findings. A reduction of target IOP should also be considered, and if the disease is at an early to moderate stage, may delay the referral.

12. 5. RECOMMENDATIONS • Any unstable glaucoma patient. iii. Optic nerve criterion - If a patient on anti-glaucoma treatment is being managed by an optometrist and there is a repeatable, clinically significant change in the appearance of the nerve fibre layer or the optic nerve, it is recommended that the optometrist refer the patient to an ophthalmologist. Our Recommendation: If a patient on optimal anti-glaucoma treatment/s is being managed by an optometrist and there is a repeatable, clinically significant change in the appearance of the nerve fibre layer or the optic nerve, it is recommended that the optometrist refer the patient. ………The optometrist should communicate the medications used and the imaging results. A reduction of target IOP should also be considered, and if the disease is at an early to moderate stage, may delay the referral.

13. 5. RECOMMENDATIONS • Acute glaucoma (or patients with chronic glaucoma presenting with extremely elevated IOP). “Raised IOP, sometimes associated with other symptoms.” In the event of acute glaucoma seen by an optometrist, referral to an ophthalmologist is requested. Treatment can be initiated while transfer of the patient to the ophthalmologist is arranged. These situations can be serious and often times the resolution of the acute IOP elevation involves laser or surgical interventions. In remote locations or when evacuation is not possible due to weather, available transportation, or general health limitations, treatment may be conducted by the optometrist after contacting an ophthalmologist, and the patient observed for reduction of IOP or adverse events.

14. 5. RECOMMENDATIONS • Acute glaucoma (or patients with chronic glaucoma presenting with extremely elevated IOP). Our Recommendation: In the event of acute glaucoma seen by an optometrist, treatment can be initiated while transfer of the patient to an ophthalmologist is arranged. Referral to an ophthalmologist is recommended, as these situations can be serious and often times the resolution of the acute IOP elevation involves laser or surgical interventions. In remote locations or when evacuation is not possible due to weather, available transportation, or general health limitations, treatment may be conducted by the optometrist and the patient observed for reduction of IOP or adverse events.

15. CONCLUSIONS “…..Optometrists already provide most of the primary eye care in Canada, being well positioned to identify the glaucoma suspects and the glaucoma cases and to provide care particularly for the less complicated and less advanced cases. Ophthalmologists have the extra training to manage the more complicated and potentially blinding conditions, which will often require surgical interventions. …….” Our Recommendation: “…..Optometrists already provide most of the primary eye care in Canada, being well positioned to identify the glaucoma suspects and the glaucoma cases and to provide treatment of most early to moderate disease. …”

16. Outstanding Issues • The need for access to Sub-Specialty Care • Equivalent standards for General Ophthalmology and Optometry for the medical care of patients with glaucoma • The ability to initiate treatment • The ability to monitor once treatment initiated (the first 3 years) • CGS are relatively OD friendly,……. COS? • Guidelines become Policy

17. HPRAC Recommendations (Jan. 2009; March 2010) • Ontario’s optometrists be authorized to treat with topical therapeutic agents patients diagnosed with open angle glaucoma; • Ontario’s optometrists be authorized to treat acute angle closure glaucoma in emergency situations only, with immediate referral to an ophthalmologist; • Patients diagnosed with glaucoma who have diabetes should be immediately referred to an ophthalmologist; • All patients under 18 who have been diagnosed with glaucoma should be immediately referred to an ophthalmologist; • All patients with neovascular or malignant glaucoma should be immediately referred to an ophthalmologist; • Any patient diagnosed with open angle glaucoma and not responding to topical therapeutic treatment should be referred to an ophthalmologist, and • Any patient with a history of conditions that contraindicate drug therapy should be immediately referred to an ophthalmologist