Optometric Learning Network in Greater Glasgow & Clyde

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Gervais Jordan
6 years ago
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1 Background Optometric Learning Network in Greater Glasgow & Clyde Recent changes within Optometry such as the changes to the Optician s Act in 2000, the more recent new arrangements regulating General Ophthalmic Services, the Glasgow Integrated Eyecare Service (GIES) and a plethora of other delegated / co-management schemes have created an environment for the development of the Optometrist s role in Primary Eyecare. Considerable discussion has taken place within GG&C with regard to fully utilising the optometric resource to broaden the scope of practice, support overburdened services in secondary care and improve the quality of eyecare overall. Key to this group of proposals is the development of a Learning Network for all Optometrists working in the GG&C area to attain the necessary skills to enable clinicians to fulfil their potential. The purpose of this paper is to develop an outline modular training framework so that practitioners can develop their own training plan dependant on experience, knowledge and existing scope of practice. All Optometrists listed to provide GOS in GG&C have already undergone a competency assessment and all practices listed to provide GOS need to be equipped to minimum standard. The Learning Network training framework will work to this set of criteria with additional proposals targeted at those with additional expertise and experience such as the GIES group, those training or qualified as Independent Prescribers and those with other Level 2 aspirations (eg glaucoma comanagement). It is hoped that the framework will allow all Optometrists to gauge their personal training needs and participate accordingly. Experience of enhanced optometric activity elsewhere (GIES, Grampian and Lanarkshire) has provided a group of the most common acute ocular presentations in Primary Care. Group One Allergic/toxic conjunctivitis, infective conjunctivitis, corneal abrasion, dry eye, episcleritis, blepharitis, sub tarsal foreign body, sub conjunctival haemorrhage, epiphora, pinguecula, pterygium hordeola, uncomplicated posterior vitreous detachment (PVD). Group Two Anterior uveitis, corneal foreign body, marginal keratitis, trichiasis, corneal erosion, viral keratoconjunctivitis, keratopathy, herpes simplex keratitis, It is accepted that not all Optometrists will be able to manage all of the conditions listed above at present, but it is hope that with additional training and appropriate inter-referral between optometrists that all of these ocular disorders could be managed within GOS. Some of these disorders might only require palliation, monitoring or referral eg pinguecula, pterygium, hordeola & PVD with the relative difficulty in diagnosis having determined the grouping. Prescribing Notwithstanding the groundbreaking work in the past by the GIES group (9 practices / 13 Optometrists) and the emergence of Optometric prescribing (approximately 30 Optometrists in Glasgow), the issue of rapidly accessing appropriate topical drugs could be a problem for those 1

2 wishing to manage acute eye presentations. Some other areas, eg Lanarkshire, have set up Patient Group Directives (PGDs)so that Community Optometrists can issue the appropriate drug to a patient without undue wait. Further close collaboration with General Practitioners, the establishment of Independent Prescribing Optometrists and the introduction of PGDs (for all Optometrists) would ensure a safe and ongoing reliable supply of medication. Referrals On the whole referrals from Optometrists to secondary care have improved since the introduction of the new GOS arrangements introduced in 2006 and this is reflected in the reduction of referrals year on year since then (ISD 2010). Recent audits, however, suggest that there is still room for improvement especially with regard to glaucoma, wet AMD, benign retinal lesions and other common conditions such as cataract and diabetic eye disease. Part of the problem has been due to confounding advice (eg NICE v CCI with regard to glaucoma referrals), poor communication and a lack of established protocols has left many practitioners confused and a robust training framework working to local referral protocols should help in this regard There are also a number of serious sight or life threatening conditions that might or might not be genuine ocular emergencies that ALL Optometrists need to be aware of so that they are able to diagnose and provide the appropriate prioritised referral required. It is proposed that the Learning Network consist of two refresher courses and several training modules that accurately reflect the needs to meet the basic GOS arrangements, an enhanced role for Optometrists within GOS and a third module for those with higher aspirations to IP, Level 2 Optometry and the co-management of chronic eye disease. In this sense the training proposals should have some relevance to all GG&C Optometrists. REFRESHER COURSE 1 Referrals to Secondary Care This course will cover the essentials for reliable, accurate referrals of sight threatening disease, life threatening disease and true ocular emergencies. It is expected that much of the training required here will mainly be classroom/didactic and workshop based. It is expected that most of this training required could be delivered by fellow Optometrists via the Learning Network and by utilising the resources at Caledonian University. Routine Referral of Common Eye Conditions: Open Glaucoma Chronic Closed Angle Glaucoma Normal Tension Glaucoma Cataract Diabetic Eye Disease Good understanding of ocular anatomy, physiology and disease process. Ability to make a reasonable diagnosis of all common eye problems. Understand the principals of Competent use of the slit lamp Competent use of slit lamp & condensing lenses. Accurate and reliable use of the contact applanation tonometer (Goldman or Perkins) 2

3 Chronic Macular Disorders Vitreo Retinal Disorders Neurological Disorders referral and adhere to the local protocols and pathways. Ability to examine & detect relevant ocular findings e.g. pathological cupping in glaucoma Accurate assessment of pupil reflexes Accurate interpretation of visual field findings Awareness of the existing Ophthalmology Care Pathways (CCI) Recognise and Refer Sight or Life Threatening Disease Acute Glaucoma Thermo chemical injury Retinal tear or detachment Signs suggestive of serious intracranial pathology Periocular malignancy New or severe uveitis Sight threatening infections Sight threatening trauma Macular disorders Including ARMD with suspected subretinal neovascularisation. Good understanding of all ocular pathology. Ability to make an accurate diagnosis of sight or life threatening conditions. Understand the nature of the condition and apply principals of prioritised referral. Ability to diagnose anterior uveitis and asses for posterior uveitis. Understanding of potential association of systemic autoimmune disease. Understand treatment options and work to local care pathway protocol. Understanding of presenting signs and symptoms Ability to make differential diagnosis of minor ocular surface damage and penetrating sight threatening injury. Good understanding of macular anatomy and disease process. An ability to recognise acute, potentially treatable sight threatening disease especially exudative ARMD. Competent use of the slit lamp and indirect fundus biomicroscopy. Referral in keeping with local protocols Urgent referral to an ophthalmologist. Accurate diagnosis of posterior uveitic disease and urgent referral. Refer urgently to an ophthalmologist following basic first aid Treat minor surface disease and urgently refer sight threatening cases. Competent use of slit lamp biomicroscopy. Additional assessment techniques to determine macular function. Refer in keeping with local 3

4 Refer urgently for further investigation & treatment to the HES. An ability to recognise chronic untreatable macular conditions and manage appropriately pathway. Giant cell arteritis, Vascular occlusions, transient ischaemic episodes. Good understanding of the vascular supply to the eye, associated structures and the visual pathway. Good understanding of ocular vascular disease. Prioritised referral as appropriate to the HES or General Practitioner. Basic Principles Record Keeping Keeping & maintaining accurate clinical records NES package Communication Skills Working with patients getting the correct message across NES package. MANAGING COMMON EYE CONDITIONS REFRESHER COURSE TWO This course relates to the conditions included in Group 1 and the essential skills that all Optometrists need to make accurate diagnosis & management of these common eye disorders. This course will also cover the essentials for reliable, accurate referrals of sight threatening disease, life threatening disease and true ocular emergencies. It is expected that much of the training required here will mainly be classroom/didactic and workshop based. It is expected that most of this training required could be delivered by fellow Optometrists through the Learning Network and possibly utilising the facilities at Glasgow Caledonian University. Management of Common Eye Disorders (Group One): Allergic & toxic conjunctivitis. Infective conjunctivitis. Good understanding of external eye disorders. Able to make an accurate differential diagnosis between Competent use of the slit lamp microscope. Safe use of relevant diagnostic 4

5 Corneal abrasion Dry Eye. Episcleritis. Blepharitis. Sub tarsal -foreign body. Sub conjunctival haemorrhage Epiphora Pingueculae Pterygium Hordeola Uncomplicated posterior vitreous detachment common conditions that can be safely managed in the community. Exclude serious sight threatening conditions that need urgent referral to an ophthalmologist. Understanding the basic pharmacological principals of treating external eye disease. Good understanding of vitreo retinal disease. The ability to make sound clinical judgements based on symptoms and clinical findings. The ability to make the differential diagnosis between simple uncomplicated PVD and sight threatening retinal disorders. and therapeutic agents. Safe removal of sub tarsal foreign bodies. Safe cross infection control. Expert use of indirect slit lamp biomicroscopy and condensing lenses. Ability to examine the posterior and anterior vitreous Indirect Ophthalmoscopy techniques. Awareness of the Flashes & Floaters Pathway (CCI) Basic Applied Sciences 1. Anatomy and physiology a. Applied anatomy and physiology of the anterior segment of the eye, lid and lachrymal drainage b. Applied anatomy physiology of the posterior segment of the eye and orbit anatomy 2. Applied Pathology and Inflammatory ocular disorders a. inflammation b. introduction to immunology c. introduction to ocular immuno pathology and allergic eye disorders d. scientific approach to controlling inflammation in the eye 3. Microbiology bacteriology, ocular virology, protozoology (acanthamoeba) 4. Ocular Genetics 5. Applied pharmacology- anti microbial agents, anti inflammatory agents,anti glaucoma agents 6. Applied pharmacology - drugs acting through autonomic nervous system 5

6 PGDs Refresher 2 To manage the above conditions the following PGDs would be required: Cyclopentolate Hyd 1%, Chloramphenicol Eye Ointment 1%, Chloramphenicol eye drops 0.5%, Fucidic Acid eye drops 1%, Lodoxamide 0.1%(as trometomal), Olopatidine Hyd 1mg/ml, Diclofenac Sodium 0.1%, Lacrilube eye ointment (liquid paraffin), Carbomer gel 980 ( Viscotears), Sodium Hyaluronate eye drops 0.4% (Clinitas), Fluoromethalone 0.1% eye drops (FML). MODULE ONE Management of Complex Acute Presentations: This module relates to the conditions listed in Group Two that will require additional training for some optometrists. Managing this group of conditions in the Community would have a significant impact on the footfall in secondary care. It is anticipated that the training for Module Two would be a mix of didactic sessions, workshops and hands on teach/treat so that practitioners will gain the essential experience necessary to manage these patients safely. Management of Complex Acute Presentations (Group Two) Anterior uveitis. Corneal Foreign Body Marginal Keratitis. Trichiasis Corneal erosion Viral Keratoconjunctivitis Keratopathy Herpes Simplex Keratitis Contact Lens related Infection Good understanding of external eye disorders. Able to make an accurate differential diagnosis between common conditions that can be safely managed in the community from serious acute sight threatening conditions that need urgent referral to an ophthalmologist. Understanding the pharmacological principals of treating external eye disease. Expert use of the slit lamp biomicroscope. Safe use of relevant diagnostic and therapeutic agents. Safe removal of corneal and sub tarsal foreign bodies. Safe cross infection control. Advanced Applied sciences 1. Anatomy and physiology a. Applied anatomy and physiology of the anterior segment of the eye, lid and lachrymal drainage b. Applied anatomy physiology of the posterior segment of the eye and orbit anatomy 2. Pathology and of Inflammatory ocular disorders a. inflammation b. introduction to immunology c. introduction to ocular immuno-pathology and allergic eye disorders 6

7 d. scientific approach to controlling inflammation in the eye 3. Microbiology bacteriology, ocular virology, protozoolagy (acanthamoeba) 4. Ocular Genetics 5. Applied pharmacology- anti microbial agents, anti inflammatory agents,anti glaucoma agents 6. Applied pharmacology - drugs acting through autonomic nervous system PGDs Module One To manage the above conditions the following PGDs would be required (in addition to those required for Refresher 2): Dexamethasone 0.1% eye drops (Maxidex), Prednisolne Acetate 1% eye drops(pred Forte), Fluoromethalone 0.1%, Betamethasone Sodium Phosphate 0.1% (Betnosol), Ciproflaxacin Hyd 0.3% Ciloxan), Ofloxacin 0.3% (Exocin), Acyclovir 3% (Zovirax). MODULE TWO Management of Chronic Eye Problems in the Community: This module relates to conditions that currently create a burden on Secondary Care and where there might be an opportunity to share this burden with Community Optometrists. Managing this group of conditions in the Community would have a significant impact on the footfall in secondary care. It is anticipated that the training for Module Two would be a mix of didactic sessions, workshops and hands on teach/treat so that practitioners will gain the essential experience necessary to manage these patients. Co-Managed Care All Conditions. Stable Chronic Eye Disease Stable Vitreo Retinal Disease Maculopathy Diabetic Eye Disease Cataract Some conditions can be managed within GOS (if the patient is discharged to the community) although some intra referral might be necessary to ensure the safe management of patients at all times. Good understanding of all ocular disorders. Good understanding of the role of other health carers. Comprehensive understanding of the clinical condition(s) that is being managed. Sufficient knowledge to manage patients safely and effectively Expert knowledge and skill set to enable the safe management and treatment of the relevant condition. 7

8 Glaucoma An expert understanding of glaucomatous eye disease. Have the clinical ability to make a differential diagnosis of uncomplicated open angle glaucoma from other more complex types of glaucoma, pigmentary, pseudo exfoliation, neo-vascular closed angle etc. Treatment options for glaucoma. Have sufficient knowledge and experience to manage & monitor treatment of open angle glaucoma. Have the clinical knowledge and skill to participate in the ongoing co-managed care of glaucoma Expert skill set in slit lamp biomicroscopy, applanation tonometry, gonioscopy pachymetry. Expert ability to assess the anterior chamber, the optic nerve head and visual field interpretation. Detecting glaucoma. Understanding the mechanisms of glaucoma Ability to provide advice and counselling to glaucoma patients on all aspects of their care, especially complying with their care regimen. Frank Munro Nicola McElvaney William Wilkie 11th April 2011 REFERENCES 1. Review of Community Eyecare Services in Scotland. SE 2005 & General Ophthalmic Services Regulations. SGHD 2006 & The Glasgow Integrated Eyecare Service. Audit. Glasgow PCT PEARS & WECE Audit Grampian Eyehealth Network audit. NHS Grampian Lanarkshire EyeHealth Network Scheme (LENS). Clinical Guidelines. NHS Lanarkshire 2010 Other suggested modules: Module 3 Glaucoma? based on the College Diploma Module 4 Diabetic Eye Disease Module 5 Macular Disorders Module 6 Binocular Vision Disorders 8

9 Module 7 Children s Eyecare Module 8 Relevant Medical Conditions to Optometry 9

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