Collaboration in many forms
When it comes to combining ophthalmic and optometric practice, Dr. Sood explains that the right collaboration model is typically tailored to a practitioner’s needs. “My optometrist partner is fully integrated into my practice—we work in tandem in the clinic, and when I’m in the operating room, she continues seeing patients. This setup works really well for me, but as we’ve expanded such partnerships within our institution, other ophthalmologists have employed a model of collaborating with an integrated optometrist who also works alongside several other ophthalmologists.”
The Cole Eye Institute even created a six-month program enabling optometrists to train with different surgeons. “This lets both sides build confidence and gives the optometrists—especially those straight out of residency—time to build their understanding of the glaucoma specialty’s needs for these collaborations; and to get a good grasp of post-operative care that takes the specifics of surgery into account.”
In-clinic, in-tandem
Optometry-ophthalmology collaboration has streamlined Dr. Sood’s patient management workflow—one example of this is the management of a 68-year-old patient who presented for a glaucoma evaluation with her optometry colleague. Another ophthalmologist had started this patient on latanoprost two months prior; however, it hadn’t really influenced her intraocular pressure (IOP)—which resided at 20 mmHg, OD, and 16 mmHg, OS—and had led to hyperemia. At this evaluation, some retinal nerve fiber layer (RNFL) thinning was noted on the patient’s ocular coherence tomography (OCT) scans (Figure 1), along with potential arcuate defects on the visual field test (VFT).
Figure 1. ONH and RNFL OU Analysis
These initial findings prompted Dr. Sood’s partner to schedule a follow-up for a repeat VFT and possible cataract evaluation with minimally-invasive glaucoma surgery (MIGS). At this initial appointment, the optometrist also switched the patient’s medication to Cosopt and provided some trial monovision lenses that the patient had expressed interest in trying. “Before, I might have spent lots of chair-time with this patient, trying to determine her expectations and whether I’d be able to reach them,” says Dr. Sood. “Instead, my optometrist took that on, and because the patient had already been given the trial lenses, when she returned—on a day I was also in-clinic—and reported that she didn’t like them, we were quickly on the same page and able to discuss next steps.” Dr. Sood ultimately performed a canaloplasty plus goniotomy, OU, with the post-operative appointments again being balanced between the optometrist (post-op day one and week one) and Dr. Sood (post-op one month). And, happy with the results, Dr. Sood left the rest of this patient’s medical management to her colleague.
There are other advantages of collaborating within the same practice. For example, in another instance, Dr. Sood’s optometry colleague used Glaucoma Workspace’s functionality to assess another patient’s—a 70-year-old White female experiencing blurry vision and aniseikonia six months post-cataract surgery—OCT changes over time, observing a steep RNFL decline of 1–1.5 µm/year over the prior four years. This, combined with multiple VFTs highlighting an arcuate defect, OD, led to a follow-up with Dr. Sood, who could pick up right where her practice partner left off. “A nice thing about working together in a practice with Glaucoma Workplace is that we can see the same data at the same time,” highlights Dr. Sood. “So when my optometry partner comes over to discuss a patient, we can be much more efficient when reviewing records.”
But as she mentions, this can only happen when the scans are available. “With glaucoma, the more data we have, the more likely we can feel confident about what the results show us. This particular case is a reminder to always perform VFTs in conjunction with OCT scans. It’s something we’ve incorporated into our practice because you can’t just rely on the latter, especially post-cataract surgery. If you’re not careful, glaucoma can end up on the back-burner.”
Multiple sites, one goal
Dr. Marrelli’s ophthalmology-optometry collaboration is set up slightly differently. “I work in a university optometry practice, seeing patients across the glaucoma continuum from suspects to late-stage.” One patient that came into her practice was a 61-year-old Hispanic man, referred due to large cup-to-disc ratios. Although his ocular history was unremarkable and his entrance testing normal, his fundus photography revealed a small disc hemorrhage, OD, and abnormally large optic nerves, OU (Figure 2), which raised suspicions when paired with an inferior nasal step, OD, in the VFT. “On his OCT, his large optic nerves were the first thing I noted—in fact, his analysis values all fell outside the reference database,” recalls Dr. Marretti. “It’s important to note that although everything on his RNFL and ganglion cell inner plexiform layer (GC-IPL) scans came up as green (or even so thick that they were white), it’s very clear that he had glaucoma. This is why it’s important to not rely on red/yellow/green as your measure of whether an OCT is normal—it’s something I’m constantly reminding myself and my students.”
Figure 2. Large ONH OU with Optic Disc Hemorrhage OD
Once she has completed the necessary testing, Dr. Marrelli can easily use Glaucoma Workspace to compile a patient’s data. “I love creating structure-function maps because they contain everything you’d want to look at regarding structure and can be imported into a patient’s chart.” This means that this data is readily available when her ophthalmologist partner comes to her practice. “I’ve been working with this glaucoma specialist for around 25 years,” she explains. “He visits monthly. In the morning, he performs all of our laser procedures; following that, he comes over to the clinic to consult on some of our more complex cases. And when a patient needs surgery, I refer them out to his practice, and he takes care of their surgical intervention, alongside the 1–2-month post-operative period.”
One of these more complex cases was of a 25-year-old White man who had originally only presented to receive new contact lenses. However, his IOP was high—being 21 and 38 mmHg, OD and OS, respectively—and his gonioscopy showed a really deep angle ciliary body band visible with a uniform, heavily-pigmented trabecular meshwork. There was almost no RNFL, superiorly in his left eye, on the red-free fundus photography—correlating to a significant inferior arcuate defect. “When I saw his visual fields, my heart just sank,” says Dr. Marrelli. “The OCT highlighted a dramatic loss of ganglion cells all around the macula. This is such a young patient with such a significant case of glaucoma. I knew it was very likely he’d need surgery at some point, leaving the question of whether to refer him now for an early introduction to the surgical discussion.” Although a complex decision, having an ophthalmology collaborator meant Dr. Marrelli could seek a second opinion on the issue.
Continuing to collaborate
Although ophthalmology-optometry partnerships are already proving beneficial, Dr. Sood highlights that their true value may come in managing future generations of glaucoma patients. “With the aging population, there’s going to be an anticipated 4.5 million glaucoma patients by 2030,1 and we only have a limited number of glaucoma specialists—expected to remain at the current level of 3500–4000,2” highlights Dr. Sood. “I’ve found collaboration really allows both partners to practice at the top of our license; together we can continue to effectively manage post-operative care, triaging, initial evaluation, and co-management to provide quality care for our patients.”
