CONCLUSIONS: Optometrists employing OCT as a routine clinical tool have a higher chance of referring patients for specialist glaucoma management than those without OCT.
OBJECTIVE: Timely detection of glaucoma is key to preventing or delaying vision loss. This study aimed to assess whether the routine use of optical coherence tomography (OCT) by optometrists for the detection of glaucomatous changes in the optic nerve and retina increased glaucoma referrals to ophthalmologists.
METHODS: This study was a retrospective review of routinely collected electronic medical records of patients from a chain of 331 optometry practices in Australia.
METHODS: Electronic medical records were reviewed for every patient aged 18-99 years who attended an included practice between January 1 and July 31, 2019.
METHODS: Odds of referral for glaucoma assessment were compared between practices performing OCT routinely on all patients (OCT practices, n=175) and without OCT (non-OCT practices, n=20). A subset of referrals were assessed by ophthalmologists to determine the false positive referral rate.
METHODS: The primary outcome measure of this study was referral to an ophthalmologist for glaucoma assessment. A secondary outcome was the rate of false positive referrals, analyzed in a subset of patients referred for glaucoma assessment.
RESULTS: Records from 994,461 patients (59% female) were included, and 10,475 (1.1%) were referred for glaucoma assessment. Most referrals were associated with normal intraocular pressure (non-OCT practices: n=496, 66%; OCT practices: n=6,603, 68%). Referral for glaucoma was higher in OCT practices (n=9,719, 1.1%) compared with non-OCT practices (n=756, 0.8%, age-adjusted, gender-adjusted, and location-adjusted odds ratio 1.39, 95% confidence interval 1.10-1.76). Of 318 referred patients (3%, all from OCT practices) for whom ophthalmologist feedback was available, 68 (21%) were considered not to have glaucoma.
CONCLUSIONS: The routine use of OCT in optometric practice may lead to more timely glaucoma detection and prevention of avoidable vision loss.

To determine whether a collaborative model of care that uses task-sharing for the management of low-risk diabetic retinopathy, Community Eye Care (C-EYE-C), can improve access to care and better use resources, compared with hospital-based care.
Retrospective audit of medical and financial records to compare two models of care.
A large, urban tertiary Australian publicly funded hospital.
C-EYE-C is a collaborative care model, involving community-based optometrist assessment and \'virtual review\' by ophthalmologists to manage low-risk patients. The C-EYE-C model of care was implemented from January to October 2017.
New low-risk patient referrals with diabetes received at a tertiary hospital ophthalmology unit.
Historical standard hospital care was compared with C-EYE-C for attendance, wait-times, outcomes and costs. Clinical concordance between the optometrist and ophthalmologist diagnosis and management was assessed using weighted kappa statistic.
There were 133 new low-risk referrals, managed in standard hospital care (n=68) and C-EYE-C (n=65). Attendance rates were similar between the models of care (72.1% hospital vs 67.7% C-EYE-C, p=0.71). C-EYE-C had shorter appointment wait-time (53 vs 118 days, p<0.01). In the C-EYE-C model of care, 68.2% of patients did not require hospital appointments and costs were 43% less than hospital care. There was substantial agreement between optometrists and ophthalmologists for diagnosis (κ=0.64, CI 0.47-0.81) and management (κ=0.66, CI 0.45-0.87).
This Australian study showed that collaborative eye care resulted in reduced patient waiting times and considerable cost-savings, while maintaining a high standard of patient care compared with traditional hospital-based care in the management of low-risk hospital referrals with diabetic eye disease. The improved access and reduced costs were largely the result of better task allocation through greater utilisation of primary eye care professionals to provide services for low-risk patients. Better resource use may free up further resources for other eye care services.

The aim of this study is to evaluate the diagnosis, staging, imaging and management preferences, and the effect of advanced imaging among practising optometrists in age-related macular degeneration (AMD).
Up to 20 case vignettes (computer-based case simulations) were completed online in a computer laboratory in random order by 81 practising optometrists of Australia. Each case presented findings from a randomly selected patient seen previously at the Centre for Eye Health for a macular assessment in the following order: case history, preliminary tests and colour fundus photography. Participants were prompted to provide their diagnosis, management and imaging preference. One additional imaging result (either modified fundus photographs and infrared images, fundus autofluorescence, or optical coherence tomography [OCT]) was then provided and the questions repeated. Finally, all imaging results were provided and the questions repeated a third time.
A total of 1,436 responses were analysed. The presence of macular pathology in AMD was accurately detected in 94 per cent of instances. The overall diagnostic accuracy of AMD was 61 per cent using colour fundus photography. This improved by one per cent using one additional imaging modality and a further four per cent using all imaging. Across all responses, a greater improvement in the diagnostic accuracy of AMD occurred following the presentation of OCT findings (versus other modalities). OCT was the most preferred imaging modality for AMD, while multimodal imaging was of greatest benefit in cases more often misdiagnosed using colour fundus photography alone. Overall, the cohort also displayed a tendency to underestimate disease severity.
Despite reports that imaging technologies improve the stratification of AMD, our findings suggest that this effect may be small when applied among practising optometrists without additional or specific training.

BACKGROUND: This research was designed to provide an in-depth exploration of the perceptions of optometrists relating to the challenges of glaucoma case finding in the Irish health-care system.
METHODS: A survey was developed, piloted and distributed for anonymous completion by optometrists registered to practise in Ireland. The survey included 10 five-level Likert items exploring potential barriers to glaucoma detection and a free-text box for participants to comment more broadly.
RESULTS: One hundred and ninety-nine optometrists (27 per cent of registrants) responded to the survey. Among the barriers identified, there was notable agreement (71 per cent) with the need for extra training on glaucoma detection. Logistic regression showed that optometrists without postgraduate qualifications were more likely to agree with the need for extra training (OR 3.2, 95 per cent CI 1.3-8.1). Respondents largely agreed (61 per cent) that patient unwillingness to pay additional fees for supplementary glaucoma-specific tests was also a barrier. Appointment times of less than 30 minutes were significantly associated with six of the 10 proposed barriers to glaucoma detection. A logistic regression analysis (n = 179) confirmed that the time allotted per appointment was a significant predictor of the agreement time of optometrists as a barrier (χ2 [1] = 13.52, p < 0.001). Multiple linear regression showed that optometrists with less experience, charging lower fees, and working in large multiples or franchised practices have the shortest appointment times.
CONCLUSIONS: The strong link found between postgraduate education and the confidence of optometrists in detecting glaucoma indicates that optometrists wishing to increase their scope of practice in the new legislative environment in Ireland may more actively seek training in areas of interest. The responses also indicate a lack of funding for the level of diagnostic testing required for accurate glaucoma diagnosis. Recent increases in the state\'s eye examination fees look likely to address the identified time and financial barriers to glaucoma detection in Ireland. Future work should look to analyse the effects of increased funding on optometric case finding for glaucoma.