Dr Andrew Angeli
DipAppSc(Optom) (QUT) GradDipOptometry (UNSW) Ocular Therapeutics (PCO, USA)
Vision Optics, Brisbane
Dr Brendan Cronin
MBBS(Hons) DipOphthSci BCom LLB FRANZCO
Queensland Eye Institute, Brisbane
Zeiss Cirrus HD OCT 500
Zeiss Humphrey Field Analyzer
Zeiss Forum: Glaucoma Workplace
Comanagement of patients by optometrists and ophthalmologists has become the default option and often best practice management for a large number of ocular conditions. Optometrists have invested in outstanding diagnostic and imaging equipment for their practices and now routinely undertake much of the ongoing observation and management of patients that was once done solely by ophthalmologists.
This comanagement has led to huge improvements in the communication between ophthalmologists and optometrists with benefits to all parties involved but most importantly, the patients.
In the management of complex or chronic diseases the inter-variation between different types of equipment can create uncertainty in conditions such as glaucoma or keratoconus, where progression in the disease requires a change in management plan. When both the ophthalmologist and optometrist have made the decision to invest in the best equipment available for their practices, it leads to the best outcome for patients. Now that optometrists have an active therapeutic role, their equipment requirements have moved from simple screening tools to highly-accurate diagnostic tools capable of performing progression and change analysis on serial scans.
The only thing better than one practitioner managing a patient extremely well with ongoing diagnostic scans that can look for subtle progression analysis is when two practitioners are using the same equipment and are both looking at the patient from a slightly different perspective.
Independently of one another, we have invested in Zeiss diagnostic equipment. The Zeiss Humphrey Field Analyzer is considered to be the gold standard for visual field assessment world-wide. The Zeiss Cirrus OCT has the ability to create a combined glaucoma report integrating both the HFA visual field and optic disc analysis to create an extremely powerful diagnostic and management tool for glaucoma.
This case involved a perfectly healthy 57-year-old man with myopia and glaucoma. Myopia is always a complicating factor when assessing visual fields, the optic disc and nerve fibre layer parameters, and macular ganglion cell analysis.
As we have found, it is enormously beneficial when comanaged patients have their scans performed on the same machines with the same software versions.
In this case, differences in the software’s analysis of the anomalies that can occur in patients with glaucoma and myopia were consistent for both practitioners. That meant improved accuracy in identifying any progression, and more timely change in management for the patient.
Obviously, another benefit is that if one practitioner has performed an OCT or visual field analysis, the other practitioner does not need to repeat the tests, saving patients time and money.
In this case, the patient had been managed by Dr Angeli for some years but had recently had an increase in his intraocular pressures to 17 mmHg, which was elevated from 14 mmHg five years prior.
The patient had been prescribed Xalatan eye-drops, one drop to both eyes at night, and was starting to become intolerant of eye-drops. At this time, Dr Angeli referred the patient to Dr Cronin for consideration for a selective laser trabeculoplasty (SLT). All of the recent OCTs and visual fields were forwarded to Dr Cronin so this imaging did not need to be repeated.
Figure 1. Ganglion cell analysis, both eyes (Zeiss Cirrus HD 500 OCT)
Figure 2. Optic nerve head and retinal nerve fibre layer analysis (Zeiss Forum: Glaucoma Workplace, Zeiss Glaucoma Progression Analysis)
Dr Cronin performed SLT to the inferior angle of both eyes and over the next six months ceased the patient’s Xalatan drops. The patient’s ocular comfort improved enormously with his redness settling and dry eye symptoms disappearing. The pressures when off Xalatan were 17 mmHg, so Dr Cronin performed a repeated SLT treatment to the superior 180 degrees of the angle. This reduced the pressures back to 14 mmHg where they have remained for more than two years. Prior to discharging the patient back to Dr Angeli for ongoing glaucoma surveillance, Dr Cronin repeated the visual fields and OCT tests and sent the images to Dr Angeli.
The obvious advantage to both patient and practitioner here is that the scans from one practitioner can be compared and contrasted to the scans from the other practitioner, knowing that any change in the imaging result is because of a change in the pathology of the patient, not a change in the software’s analysis of the patient’s anatomy.
How an optometrist’s equipment will interplay with that of the ophthalmologist they routinely refer to is an important component of the decision-making process of determining which equipment will be best suited to their practice.
Optometry and ophthalmology comanagement now forms the basis of eye-care treatment in Australia. Utilising the same equipment takes this close relationship to the next level of professionalism that serves to benefit patients through early diagnosis and treatment of abnormalities.
Dr Andrew Angeli is an optometrist in the suburb of West End in Brisbane. He has a therapeutic-focused practice with a large number of patients whom he has been managing for decades.
Dr Brendan Cronin is a corneal and anterior segment surgeon with a particular interest in micro-incisional glaucoma surgery with the Hydrus stent. Their practices are geographically close and they have a large number of patients whom they comanage.