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GLAUCOMA REFERRAL

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									Procedure for Glaucoma
  Referral Refinement




                                        Version No : 2   Number of pages :
Date of Issue : 17th December 2009      Date of Next Review:
Date of Authorisation : 17th December
2009
                                        Post Responsible for Review:
                                        Optometry Commissioning Manager
Authorised by : S Hall


Distribution : CECPCT Intranet Site
Version Control Sheet




 Version    Date           Author     Status                Comment
1                     Sally Hall      draft
2          27/11/09   Sally Hall      draft    Alterations to sections 3 and 4, as
                                               per comments made.
                                               Appendix 2; fees.
3          17/12/09   Sally
                      Hall/Lyndon     Final
                      Taylor
4          18/12/09   Lyndon Taylor   Final    Corrected corrupt files
                                 Contents



1. Introduction

2. Aim

3. IOP pathway

4. Visual Fields pathway

5. IOP & Visual Fields pathway

6. Appendices
   1. Introduction

This procedure is intended to be used by Optometrists working independently in
the community. This protocol has been developed to be compliant with NICE
guidance: Glaucoma; Diagnosis and management of chronic open angle
glaucoma and ocular hypertension (April 2009).


  2. Aim

The aim of the procedure is to ensure that only patients who have either
repeatable intraocular pressures (IOP’s) of greater than 21mmHg or have
repeatable small visual field defects are referred to Ophthalmology. Patients who
do not have repeatable defects are therefore able to remain in local primary care.
  3. IOP Pathway


  i.   If at first sight test IOP >21mmHg in either eye, by whichever method you
       choose, repeat IOP, at same time.
 ii.   Repeat with slit-lamp mounted Goldmann Applanation Tonometry (GAT)
       or Perkins, with disposable probe.
iii.   If IOP >21mmHg, in the same eye request referral to Ophthalmology via
       Patient Choice centre (see appendix 6; referral/claim form).
iv.    Give the referred patient a Patient Choice letter (appendix 5).
 v.    If IOP ≤21mmHg patient does NOT need to be referred BUT the
       referral/claim form should be completed and sent to Patient Choice centre
       for payment (appendix 6).
vi.    Fee paid for repeat IOP check, if carried out as stated above is detailed in
       appendix 1.
vii.   See appendix 2 for flow diagram of IOP Pathway


  4. Visual Field Pathway

  i.   If at first test IOP ≤ 21mmHg, no other sign of glaucoma is present (disc
       changes, splinter haemorrhages) but there is a small potentially
       ‘glaucomatous’ visual field defect repeat the Visual field within 14 days but
       NOT on the same day.
 ii.   ‘Glaucomatous’ visual field defect being classed as: 1 pt or more missed
       on 40 pt screening test; 2 or more missed on 60pt screening test; GHT
       borderline or worse; FDT same square missed on 2 occasions at any
       level.
iii.   Repeat test must be:
            Not fewer points than original test
            Minimum 60 point test
            Supra-threshold
            Or sita or sita-fast 24-2 or equivalent
            Carried out between 1 -14 days after the first test (i.e. not on
                the same day)

iv.    Unless the repeated field shows a defect in the same area as the first test
       then it should not be considered significant and NOT referred to
       ophthalmology.
 v.    If the repeated field shows a defect in the same area as the first test then it
       should be referred to Ophthalmology via Patient Choice Centre (see
       appendix 6; referral form) including BOTH first and second visual field test
       printouts for BOTH eyes.
vi.    Give the referred patient a Patient Choice letter (appendix 5).
vii.   If patient does NOT need to be referred the referral/claim form should be
       completed and sent to Patient Choice centre for payment (appendix 6)
       along with copies of BOTH visual fields.
         viii.     Fee paid for repeat field, if carried out as stated above, is detailed in
                   appendix 1.
          ix.      See appendix 3 for flow diagram of Visual Field Pathway.



                 5. IOP & VF Pathway

         i.        If at first test IOP > 21mmHg and there is a small potentially glaucomatous
                   visual field defect present, without any other sign of Glaucoma, repeat
                   IOP at the same time with GAT or Perkins.
        ii.        If IOP >21mmHg, in either eye, refer to Ophthalmology via Patient Choice
                   Centre.
       iii.        If IOP ≤21mmHg repeat visual field within 14 days (as Visual Field
                   Pathway)
       iv.         Unless the repeated field shows a defect in the same area as the first test
                   then it should not be considered significant and NOT referred to
                   ophthalmology.
        v.         If the repeated field shows a defect in the same area as the first test then it
                   should be referred to Ophthalmology via Patient Choice Centre (see
                   appendix 6; referral form) including BOTH first and second visual field test
                   printouts for BOTH eyes.
    vi.            Give the referred patient a Patient Choice letter (appendix 5).
   vii.            If patient does NOT need to be referred the referral/claim form should be
                   completed and sent to Patient Choice centre for payment (appendix 6)
                   along with copies of BOTH visual fields.
  viii.            Fees paid will reflect if IOP only or IOP and VF are repeated. See
                   appendix 1.
       ix.         See appendix 4 for flow diagram of pathway.


                 6. All pathways

 i.                Recall interval is left to your professional judgment. Consideration should
                   be given as to whether the patient is likely to produce consistent field
                   tests.
ii.                Please send all referrals to the Patient Choice centre immediately by fax
                   or post if the practice doesn’t have a fax machine or when sending visual
                   fields. If posting please advise the patient to leave at least 4 days prior to
                   calling the Patient Choice centre.
iii.               Fees have been agreed with the Cheshire LOC, as set out in appendix 1,
                   and will be paid monthly by Cheshire Health Agency.
iv.                All claims for fees will be subject to audit by the PCT. The PCT reserves
                   the right to recover fees paid for incorrect claims.
v.                 The PCT will be auditing results from the scheme to ensure that the
                   original aim is being answered.
                                                                     Appendix 1
                                     FEES



Pathway                    Fee paid (per patient)      Fee paid (per patient)
                           Full fee                    for practices partaking
                                                       in loan scheme *
IOP repeat                 £15.00                      £10.00
Visual Field repeat        £25.00                      N/A
Field and IOP repeat
(where both tests are      £40.00                      £35.00
competed) **



* this applies for first 150 patients seen only. The fee will then
automatically revert to the full fee.


** for patients that only require repeat IOP and are then referred the IOP
repeat fee will be paid only.
      Glaucoma Referral Refinement Pathways
                                                                Appendix 2

         Raised IOP without any other sign of Glaucoma
                                                                      2009
Requires Level 1 Optometrists

                                Routine sight test
                                 by accredited
                                  Optometrist

                                      IOP
                                  >22mmHg
                                 with puff air
                                 No other sign
                                 of Glaucoma
                                    present


                                Slit-lamp
                                Mounted
                               Goldmann
                              Applanation
                            Tonometry (GAT)
                               Or Perkins

                                  Same day re-
                                     check



             Give patient
             the Patient
            Choice centre
                letter


          IOP > 21mmHg                               IOP ≤ 21 mmHg
            with GAT                                    with GAT

             Refer to                                  Discharge
          secondary care
              service                                 Send referral
                                                     form to choice
            Send referral                                centre
           form to choice                               Fee £15
               centre
              Fee £15
Glaucoma Referral Refinement Pathways                   Appendix 3

     Visual Field Defect without any other sign of Glaucoma

                                                                     2009

                          Routine sight test
                            by scheme
                            Optometrist

                           GLAUCOMATO
                             US VISUAL
                           FIELD DEFECT
                           No other sign of
                              Glaucoma
                               present

                           Repeat Fields
                     Arranged for another day within
                      2 weeks
                     Min 60 point threshold test
                     Send both copies to choice
                      centre




               Give patient
               the Patient
              Choice centre
                  letter



                Defect still                       Defect not
                 present                            present

                 Refer to                          Discharge
                secondary
               care services                      Send both
                Send both                        copies of VF
               copies of VF                      and form to
               and form to                      Choice Centre
              Choice Centre                        Fee £25
                 Fee £25
                                                         Appendix 4
   Raised IOP and small ‘glaucomatous’ visual field defect



                     Routine sight test

                     IOP: >21mmHg and
                      Visual Field: small
                    ‘glaucomatous’ defect




                         IOP Re-check
                   Slit-lamp mounted GAT
                    or hand held Perkins
                     Same day re-check




  IOP <22mmHG                                 IOP >21mmHG




                                              Refer to secondary
Repeat Visual Fields                                 care
 Arranged for another
  day within 2 weeks                          Send IOP form to
Min 60 point threshold                         choice centre
                                                  Fee £15


  Defect still           Defect not present
   present                   Discharge
   Refer to
secondary care           Send both copies
  via Choice             of VF and form to
    Centre                Choice Centre
                              Fee £25
  Send both
 copies of VF
 and form to
Choice Centre
   Fee £25
                                                     Appendix 5




Further to your appointment today, I would like arrange for
your onward referral to the appropriate hospital. To do this,
you will need to contact one of the Patient Care Advisors at
our appointment centre.



      Please contact the Appointments Centre
                 by telephone on

                       01270 376594




   The opening hours of the Appointment Centre are

             Monday to Friday 9am to 5.00pm

Please contact the Administration Centre 24 hours after
receiving this information and ideally within three working
days, unless otherwise advised by your Optician.

To ensure patient confidentiality.

 When you telephone the Appointments Centre, you will be
     asked for your Name, Date of Birth, your General
  Practitioner and his/her Surgery’s name to confirm your
                           identity.
     GLAUCOMA REFERRAL REFINEMENT
Surname:                                    Other names:                                     Date of Birth:
Address:
Postcode:                                                     Telephone Numbers:
GP Name:                                                    GP Practice:
THIS PATHWAY IS ONLY FOR PATIENTS REGISTERED WITH C&ECPCT GPs WITH NORMAL OPTIC DISCS. If there
are disc changes or the patient is registered with a GP from another area please refer via GOS18 as usual.
      IOP
                         Date             Time                   Instrument         RE                             LE
Original (from                                         (specify)
Sight test)
Repeat (Must be
with Goldmann
                                                       Goldmann             
orPerkins)                                             Perkins              
Do not refer for IOP alone unless at least one eye is over 21mmHg on BOTH occasions
Visual Fields
                      Date         Time           Instrument                    RE                                 LE
 Original
(from Sight test)
                                                                   Normal                            Normal                 
                                                                   Suspicious                        Suspicious             
Repeat
(On different
                                                                   Normal                      Normal                       
date. Minimum
60 pt Supra-
                                                                   Inconsistent defect         Inconsistent defect          
threshold or SITA
24-2)                                                              Consistent defect           Consistent defect            
Do not refer for Visual Field defect alone unless there is a consistent defect in the same area of the plot on BOTH
occasions. If claiming for VF repeat then you must include printouts of both the original and repeated fields.
Patient does not                       Patient needs                                 If referral required, please
need referral                         referral                                     fill in the details below
Prescription Details
                    Uncor V     Sph         Cyl        Axis     Prism       Base            VA            Add           Near VA
RE
LE
Please record CD ratios here           RE                                       LE
Other Information




Claiming For:                  √        Optometrist:                                 Practice Stamp

Repeat IOP                     
                               
                                        Signature:
Repeat Fields

Fields & IOP                   
Post or Fax this form to Patient Choice, DRSS, Eagle Bridge Health & Centre, Dunwoody Way, Crewe, CW1 3AW
FAX: 01270 509632. Don’t forget to include VF printouts if

								
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