Optometry and the Glaucoma Sweet Spot

Glaucoma, especially open-angle glaucoma (OAG), is an insidious disease and one of the world’s most common causes of sight loss. It is also notoriously difficult to detect, diagnose, and deter the onslaught of danger that increased intraocular pressure (IOP) presents. And though glaucoma’s high profile has inspired a promising wave of innovations, there remain key challenges in both diagnosing and managing the disease.

The main problem is the gargantuan pile of appointments and tests it takes to root out and manage the progression of glaucoma. Detection is difficult — especially in the early going. Oftentimes, a diagnosis then requires a battery of follow-up tests for confirmation. Management is time consuming. As the disease progresses, IOP must be monitored, efficacy of drugs measured, and regimens adjusted.

Glaucoma is manageable, yes — but it does not go gentle into that good night.

Screen to win

Enter optometrists, whose roles worldwide are progressively expanding into that of primary eye care provider. This expansion puts optometrists directly in the sweet spot of glaucoma management, and Dr. Monica Chaudhry, an optometrist on the front lines of bridging the glaucoma gap, knows why.

“The whole concept of optometry, when it evolved from opticianry, was a clinical person who has to be the primary eye care screener,” she explained. The first step in managing a disease is detecting it, and glaucoma screening is a complex beast.

One of the unique features of glaucoma is the challenges of early detection. Around 50%1 of people that have glaucoma do not know they have it. Damage to the optic nerve is slow, and the signs non-existent or subtle. Optic nerve damage is also irreversible, and by the time noticeable vision loss is observed, glaucoma has already done most of its work.

“It is this time [in the early stages] when the patient should be screened, and that’s how we can keep the vision safe and preserved,” Dr. Chaudhry noted. “The patient is picked up well in advance and protected from [optic nerve damage],” she added.

That’s the spot!

Screening is thus a massive void in the glaucoma management puzzle.

Dr. Chaudhry believes that there are many reasons why optometrists, as primary eye care providers, are the best candidates to fill this and the many other holes.

The first is time. Ophthalmologists are not known to have many empty slots in their appointment books, and this is a harbinger of a looming shortage of MDs.

The density of ophthalmologists in the United States decreased from 6.3 per 100,000 in 1995 to 5.68 by 2017.2 And with an aging population, this hunger for expertise will only increase — the Health Resources and Services Administration believes that by 2025, there will be a shortfall of around 6,000 ophthalmologists in the United States.

Quarts of (digital) ink have been spilled elsewhere debating the ‘whys’ of this shortfall. But one of the clear answers is the sheer amount of time it takes to train an ophthalmologist. With 10 (or more) years of education to complete a full course of study, it's not surprising that the population is far outpacing the supply of fresh MDs.

This time crunch has knock-on effects well outside of crowded appointment books. Dr. Chaudhry pointed out that this leaves ophthalmologists geographically scattered, and in her native India, more concentrated in urban areas.

“Patients need at least an hour or two for the total process of [tests]. If you restrict them to a few places, people will find it difficult to travel and they’ll skip off these tests,” she said.

This is especially important in rural areas, and it is not only screening that is at stake. “For monitoring, if someone living in a rural area has to travel 500 kilometers and spend money out of their earnings, it’s not possible,” Dr. Chaudhry added.

The glaucoma management sweet spot thus takes shape. The need clearly exists for a practitioner that can be trained (relatively) quickly at enough depth to pick up on the subtleties of glaucoma detection — all with the ability to set up shop away from major hospitals.

These mystery practitioners, of course, are optometrists. And there are even more boxes that they check that go beyond even the capabilities of ophthalmologists.

Dr. Chaudhry believes there are subtle things that are invaluable in detecting glaucoma early. “Any patient who comes to me for vision correction, even if I have not done the investigation, there are certain signs. Does the patient have any family history or parents with glaucoma or unexplained headaches? Does the near number keep changing? Are there contrast problems?”

All things that an ophthalmologist, who sees a patient only a few times in their life might miss. Things that an optometrist who sees the same patient regularly would pick up on.

Put me in, coach

There is a mountain of evidence pointing to optometrists playing a bigger role in glaucoma detection and management. But obstacles remain, both in Dr. Chaudhry’s native India and around the world, to ODs shouldering a burden for which they are seemingly custom-designed to bearing.

Dr. Chaudhry believes that the first step is education for prospective patients. “A lot more awareness campaigns for patients to please visit and have a routine eye screening need to be done,” she argued. In this way, patients who might have 6/6 vision but are exhibiting other early warning signs can go get checked properly.

This goes hand in hand with optometrist education. “The professionals of course have to be very well trained. Supposing we built up patient awareness, the cycle has to be completed and the optometrist has to be well trained in handling this equipment and conducting screenings,” she continued. “We need more skilled optometrists, and we need public awareness at the same time.”

Equipment is the next big step. From tonometers to slit lamps and gonioscopes, the kit needed to be confident in a diagnosis is numerous and expensive. “Glaucoma screening and the equipment cost money, and the patient has to also pay for these things. It’s a vicious cycle,” Dr. Chaudhry noted. “Optometry needs investments.”

One of the best ways to drive investment, especially from government, is through demand. “Many of these devices which industry makes — if the sales increased, the costs would also come down,” she observed. And of course, demand is driven by more practicing optometrists, who in turn can do their job more effectively with equipment subsidized by governments, the industry itself, or even NGOs.

In the end, there are many ways to get over the obstacles to getting more optometrists activated in the fight against glaucoma. Equipment cooperatives where multiple optometrists take turns using subsidized advanced detection and monitoring equipment is one that helps keep costs for patients low.

Organizations like Dr. Chaudhry’s Learn Beyond Vision, an online optometry upskilling education platform, also aim to keep existing optometrists abreast of the latest developments and research. “We are qualified enough to handle this. You have existing professionals, you just need to upskill them. Training and education is the key,” she concluded.

And while much needs to be done, the bottom line is clear — optometrists can and should play a bigger role in glaucoma management, and the avenues for getting them involved are as many as they are promising.

References

1. Don't let glaucoma steal your sight! Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/visionhealth/resources/ features/glaucoma-awareness.html/. Accessed on January 2, 2023.

2. Supply and demand: Navigating the future of ophthalmology. Healio. Available at: https://www. healio.com/news/ophthalmology/20210707/ supply-and-demand-navigating-the-future-ofophthalmology. Accessed on January 2, 2023.

Contributing Doctor

Dr. Monica Chaudhry is a consultant optometrist and educator who has more than three decades of experience as an academic and clinician. With her extraordinary skills in optometry education, she has recently ventured to be a freelancer educator, strategy advisor, and practitioner. She is the founder of an online optometry upskilling education platform, Learn Beyond Vision. Also, she has instituted some centers of excellence and vision centers, which aim to be a unique referral, academic and research units. She is well-known contact lens and low vision specialist and has a far and wide patient referral in India. Dr. Chaudhry has served at the All India Institute of Medical Sciences (AIIMS) in New Delhi, had academic experience with various universities, including the Indira Gandhi National Open University (IGNOU) and Amity University (India), and has recently retired as director of School of Health Sciences at Ansal University (Gurgaon, India). In recognition of her contribution to the field of academic medical service, she has been awarded the Shreshtshree Award by the Delhi Citizen Forum, the Australian Leadership Fellowship award in 2012 and the IACLE Contact Lens Educator of the Year (Asia Pacific) award in 2015. Dr. Chaudhry was chairman of the Optometry Council of India. She has been actively involved in organizing conferences, seminars, national and international workshops, faculty development programs and many corporate training programs. monica.rchaudhry@gmail.com