Glaucoma disc referrals from DESP

Transcription

1 Glaucoma disc referrals from DESP Gilli Vafidis Brent DESP

2 Plan Glaucoma referrals and National Screening 2 studies from Brent Audience discussion around pros and cons of referring optic discs from DESP (glaucoma)

3 National Guidance and choice This is not a glaucoma screening programme! But 1/3 of all glaucoma in our populations is undiagnosed There are 2 choices for commissioners for cupped discs not in-care: 1. Refer back to GP (letter cc patient) for preferred local pathway 2. Refer into a glaucoma clinic via other diagnosis

4 Current Brent DESP-glaucoma pathway Return to AR ROG Disagree 1 0 / 2 0 grader suspicious disc (known glaucoma excluded) Agree Referral to Glaucoma Clinic alert 1.IOP 2.Field 3.Disc

5 1 st study: All suspicious discs Study Questions How good is ROG at judging glaucomatous discs in DESP? How many people with referred discs have glaucoma at 1 year? Epub ahead of print J Glaucoma 2012: Hon Shing Ong, Samantha Levin, Gillian Vafidis

6 1 st Study: Method DM population photographed over 16 months 1 0 / 2 0 DESP grade: Suspicious Optic Discs ROG decides glaucoma / no glaucoma Glaucoma expert (reference standard) decides glaucoma/no glaucoma Positive glaucoma grade GLAUCOMA CLINIC

7 1 st Study: Results DM population photographed 216 (1.9%) Suspicious Optic Discs 1 0 / 2 0 DESP grade ROG 147 glaucoma 69 no glaucoma Glaucoma expert (reference standard) 170 (79%) Positive glaucoma grade GLAUCOMA CLINIC

8 Results: 135 patients at 1 year Glaucoma Glaucoma Suspect No Glaucoma

9 Results of suspicious disc referral for glaucoma 2/3 of all seen were diagnosed glaucoma (drops) or glaucoma suspects at 1y (positive cases)) Average IOP between positive (16.9mmHg) and negative (16.3mmHg) cases was not significantly different Presenting IOP was > 21 in 11% of positive cases Interobserver agreement (ROG and glaucoma expert) 76% (kappa value 0.4)

10 Discussion As presenting IOP was > 21 in a minority (11%) of positive cases, addition of IOP test in screening would probably not add benefit Glaucoma suspect rate of 50% is not higher than that of glaucoma referrals from other sources Study limitations: bias and inability to comment on patients not referred to ROG But public health cost if ignore long-term consequences of preventable glaucoma blindness

11 Key Points: Glaucoma Glaucoma is the commonest cause of preventable irreversible blindness worldwide Once lost, sight cannot be recovered Aim: Rx to maintain sighted lifetime Most people treated for glaucoma will not go blind People with glaucoma need lifelong monitoring Most glaucoma is treated with eyedrops Glaucoma can run in families Importance of the patient s role in their own treatment regular eye drop application important prognosis for sight Early glaucoma is symptomless

12 2nd study: disc haemorrhages (ongoing) In DR - how useful are disc haemorrhages at case finding glaucoma? But 1. Will history of disc haemorrhage influence glaucoma clinic outcome? 2. The glaucoma clinic does not routinely look at DESP images of referred discs

13 2nd Study: Method DM population photographed over 24 months 1 0 / 2 0 DESP non-referral grade: Optic Disc haemorrhage ROG judges disc normal / abnormal GLAUCOMA CLINIC

14 2 nd Study: Results Approx 30,000 DM population photographed 112 (0.37%) Optic Disc haemorrhages 1 0 / 2 0 DESP grade ROG Normal / Abnormal GLAUCOMA CLINIC

15 Comments from results interim analysis We had expected more than 5% normal follow ups because of history of disc haemorrhage Close analysis needed Who makes pathway decisions in the glaucoma clinic? What is the hierarchy of data decision making in the glaucoma clinic? Should more use should be made of annual disc photographs in DESP to save HES clinic follow-up?

16 Discussion: What do others do in their programmes? Bearing in mind A. There are >1m glaucoma related visits to eye clinic annually (making up 15% new, 25% follow up of all activity) B. The screening test is funded and already being done in DM population annually normal cupped