Training Non-Physicians to Recognize Signs of Glaucoma
Chat Highlights
December 21, 2005

On Wednesday, December 21, 2005, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Training Non-Physicians to Recognize Signs of Glaucoma."

Moderator:  January is National Glaucoma Awareness Month.  Again we will hear that nearly half of the more than two million Americans age 40 and older who suffer from glaucoma do not know they have the disease.  How aware of glaucoma are general practitioners?

Dr. Rick Wilson:  Unfortunately, most physicians are ignorant of the early diagnostic signs of glaucoma.  It takes continual educational effort, as new waves of health-care providers take the place of retiring ones all the time.  The American Academy of Ophthalmology has outreach and medical education programs for non-ophthalmologists, but I don't know how often that is taken advantage of.

P:  Since many primary-care practices now have physician assistants and nurse practitioners seeing patients, they, too, must be ignorant of the early diagnostic signs of glaucoma.

Dr. Rick Wilson:  Continued outreach to the professional associations of physician assistants (PAs), general medical doctors, family practitioners, and internists is needed to stimulate the associations to include educational material about glaucoma to their members.

P:  Doesn't it take special tools to recognize glaucoma?

Dr. Rick Wilson:  An ophthalmoscope or a slit-lamp biomicroscope with a special lens is needed to see the optic nerve.  Often a visual field machine of some kind is also used.

P:  Is there a branch of any of the glaucoma specialists' organizations that has a mandate for this kind of education?

Dr. Rick Wilson:  There's the American Academy of Ophthalmology, along with its foundation, EyeCare America, and the American Glaucoma Society.  Their efforts, however, are not as well-funded and vigorous as I would like.

P:  Can some screening tests for glaucoma be performed easily by non-physicians?

Dr. Rick Wilson:  Not really. Screening for glaucoma by taking eye pressure is a poor method for discovering glaucoma.  The rest of the tests are more involved, though many volunteers are smart enough to learn to administer them.

P:  Are we talking about recognizing the possibility of glaucoma, and thus an exam by at least an optometrist?

Dr. Rick Wilson:  We are talking about recognizing glaucoma at a stage before it becomes a functional impediment.  Again, it is difficult to screen for early glaucoma without training.

P:  If the air puff tests used to measure intraocular pressure (IOP) at health fairs, etc., are not adequate, how can IOP be measured?

Dr. Rick Wilson:  The air puff is inaccurate, but even having an accurate pressure reading is a poor way to screen for glaucoma.  Too many people have borderline high pressures without any damage, and too many other people have normal-tension glaucoma and would be missed.

P:  Are you saying that non-physicians can't really recognize signs of glaucoma?  That all they can do is learn when to refer a person to someone who can?

Dr. Rick Wilson:  I am saying that non-physicians cannot recognize signs of glaucoma.  They can only give a risk questionnaire and tally up the risk factors to know when to refer.  Even screening by eye doctors is not an efficient way of discovering glaucoma, unless the group screened is at increased risk, such as in a retirement home, or are older African Americans or Hispanics.  Otherwise, it costs about $2000 for every case brought to light.

P:  I'm afraid I don't understand what you meant by "Even screening by eye doctors is not an efficient way of discovering glaucoma unless the group screened is at increased risk . . . Otherwise, it costs about $2000 for every case brought to light."  How else can you find glaucoma other than by eye exams?

Dr. Rick Wilson:  I mean that randomly screening people for glaucoma is not cost or time effective.  It becomes effective if the group screened is at high risk for glaucoma, such as the groups I mentioned above.

P:  How often should people at high risk have eye examinations and what would the examinations involve?

Dr. Rick Wilson:  The eye examination should take place every year and should include a thorough examination of the optic nerve, a slit-lamp examination, and an IOP reading.

P:  I live in Vermont and was told that in this particular state optometrists are now, or soon will be, licensed to treat glaucoma medically.  I seem to recall hearing that they will also be permitted to perform some types of surgery.  Some months ago an optometrist showed me a thick Wills' manual that he'd just received to help prepare him to provide glaucoma treatment. Can you please comment?

Dr. Rick Wilson:  What a practitioner is allowed to do is determined by the state legislature.  Legislatures are often influenced by factors other than what is in the best interest of the patient. In states where optometrists have been allowed to treat glaucoma, optometrists are required to take a short course on glaucoma medications and their use.  They usually don't undergo a preceptorship, where they treat glaucoma patients under the supervision of a teacher.

P:  Do you think most optometrists would be capable of treating glaucoma?

Dr. Rick Wilson:  I think the majority would be uncomfortable treating cases of severe glaucoma.  Some optometrists have taken extra training and do a satisfactory job, but the majority are under-trained.

P:  It would seem sensible to me for insurance companies to provide information and guidance to the public.  Our family medical insurance provides a dollar amount for a yearly eye exam by an optometrist, but doesn't make plain any need for an exam.  Until I ran into trouble myself, I didn't have eye exams of any kind, except once in a great while to get new glasses.  What efforts are insurance companies making to educate the public?

Dr. Rick Wilson:  The federal government and third-party payers are investigating quality-of-care markers.  For diabetics, that could mean a yearly eye exam for glaucoma and diabetic retinopathy.  For anyone over age 65, that could be a mandatory, yearly eye exam.  There is definite progress; it is just slow.

P:  Do you think that children should be examined at least once by an ophthalmologist? Or is it only worthwhile if there is a problem or family history of eye disease?

Dr. Rick Wilson:  I think children should be seen by an ophthalmologist before they start kindergarten.

P:  In my area, there seems to be an atmosphere of mutual respect between the ophthalmologists and optometrists, and there are referrals between them.  Aside from the issue of medical treatment of glaucoma by optometrists, in your opinion are individuals in that profession sufficiently trained to recognize glaucoma in its various forms?

Dr. Rick Wilson:  Both ophthalmologists and optometrists need further training to recognize early glaucoma, although ophthalmologists are better at it.  Both can discern fairly advanced glaucoma.  A number of optometrists who send me patients are very sharp.  Training and ability, however, vary a great deal.

P:  My optometrist was great.  Although his screening test said "no glaucoma," he was still suspicious and sent me to a specialist. I'll be forever grateful.

Dr. Rick Wilson:  I am going to have to leave as I need to be in New Jersey at 7:15 tomorrow morning to start seeing patients.  Happy holidays to everyone.  I hope 2006 will be a healthy year for us all.

Moderator:  Thank you, Dr. Rick. Happy holidays to you and your family from all of us.  We deeply appreciate the time and effort you have given us this year and many years in the past.
End

On January 11, Dr. Werner discussed "Do I Really Need All These Drops and Why Do They Cost So Much?" in the Chat room. Click here for highlights of that meeting.

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