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The Future of Glaucoma
A clear vision for a better tomorrow: The Future of Glaucoma can be brighter
Future of Glaucoma Care in the UK
Shaping the future of glaucoma care at every level will not only improve patients’ lives but deliver lasting benefits for society, finds Michael Marshall.
This article was commissioned and funded by Santen.
A glimpse of a better future
It’s 2030. Wunmi pops into her local pharmacy for a routine eye check. A recent arrival in the UK, Wunmi has had limited access to eye care in her 50 years – but she saw an advert on social media advertising free eye health checks.
A five-minute scan, enabled by artificial intelligence (AI), flags Wunmi as having a high glaucoma risk. Two weeks later, she is reviewed virtually by a consultant, who confirms that she has high intra-ocular pressure and other risk factors.
Wunmi is given a clear, personalised treatment plan and a digital eye passport she can check on her phone. An advisor from Glaucoma UK follows up later that week, which is handy because Wunmi realised she didn’t think to ask if she can keep her driver’s licence.
Over the next few years, Wunmi never falls through the cracks in the healthcare system, even when she moves to a different county to start a new business. After a few years she has an intra-ocular implant, which removes the burden of self-administering eye drops, and avoids the need for surgery. This continuous care and smooth data sharing means she never loses vision and she doesn’t need time off work. Wunmi’s business becomes a success, employing others, supporting her family, contributing to her community and the economy. All because the system caught her early.
The same week the consultant meets Wunmi, he also sees Leo: a 76-year-old with advanced glaucoma, memory issues, and no family nearby. Leo is a complex case of glaucoma: he needs a home visit and close follow-up. Thanks to time freed up through smarter triage, the consultant and her team can give him the care he needs without delay.
Multiply these experiences by tens of thousands. A smoother and more targeted glaucoma care system will mean fewer emergencies and less avoidable blindness. Eye surgeries will be used only when truly necessary, and performed by specialists with time to take care. The glaucoma care workforce will no longer be buried in backlog, but focused on the people who most need their expertise.
From vision to reality
Our panel of experts identified many recommendations for improving the glaucoma care system. For ease of use, the recommendations have been grouped according to the level at which they operate: hospitals and the local area, regional, and national. This reflects the fact that improving glaucoma care requires a concerted effort across many areas of the healthcare system, from optometrists serving their local community all the way to the national government.
LOCAL/HOSPITAL RECOMMENDATIONS
At the local and hospital level, one of the most pressing issues is the care system’s fragmentation. There is an urgent need to ensure that patients and their data move smoothly through the system. This will improve the efficiency of healthcare, and patients’ experiences and outcomes. To achieve this, we have identified six sets of recommendations.
Transition to electronic patient records (EPR); in tandem:
- EPRs should be shared with optometrists, ensuring continuity of care.
- EPRs should be linked directly to appointment booking software, to reduce loss to follow-up.
- The EPR medication section should be integrated with general practitioners (GP) and pharmacies, to aid timely changes of drops and avoid gaps in prescriptions.
- EPRs should integrate with other equipment and software, e.g. visual field, optical coherence tomography (OCT) and genetic data repositories.
Standardise the process of glaucoma care:
Standardise progression platforms (ideally with built-in EPR).
- Create clear patient referral pathways.
- Standardise the OCT used in each area.
Use AI to aid decision-making:
- Deploy an AI risk-assessment tool to help direct patients to the most appropriate clinic (virtual, face to face or general).
- Use automated decision support tools: AI can help to identify cases that require special attention.
- Use risk stratification to determine follow-up intervals and who is responsible for each patient.
Improve health equity and access to care:
- Make it easier for patients to contact glaucoma services, by adopting text messages and staffed switchboards: this will help ensure appointments are fruitful.
- Increase clinic capacity and times and locations where/when patients can attend.
- Maintain and improve treatment hubs, image acquisition clinics and virtual review clinics.
- Work with geriatricians in falls clinics and domiciliary optometrists in care homes to improve detection of eye disease.
Improve patient engagement and education via:
- Routine referrals to third-sector support at diagnosis and other key touch-points.
- Automatically adding the Glaucoma UK banner to patient letters.
Create systems to identify and rectify mistakes:
- Implement failsafe processes for patients who do not attend appointments despite being in the system.
- Address care backlogs using failsafe processes and officers.
- Set up an ongoing automated audit process to support quality control.
REGIONAL RECOMMENDATIONS
Regional glaucoma care would benefit from a greater degree of systematisation and standardisation. From the pathways patients follow through the system, to the way their data are handled, a more systematic approach would bring significant improvements. There is also a great opportunity to make more use of community optometrists, who have valuable skills that are currently under-used, and would help to ease pressure on hospitals. We identify five sets of recommendations.
Improve systems for identifying glaucoma cases early:
- Practice active case-finding and/or targeted screening.
- Implement targeted case-finding in underserved communities. Begin with pilot projects, then scale up and share learnings.
Standardise regional processes of glaucoma care:
- Create dedicated glaucoma hubs for case-finding and treatment.
- Standardise referral pathways, including use of treatment hubs and virtual clinics, to ensure efficient patient follow up.
- Standardise risk assessment tools.
Integrate the many components of the glaucoma care system, to make the most of community optometrists and other local actors, and ensure more effective identification of undiagnosed patients:
- Improve integration between Hospital Eye Services, optometrists, GPs and pharmacies. For instance, they could all have access to the same EPR platform.
- Introduce glaucoma screening services by optometrists, separate from vision checks, to better identify possible cases.
- Discharge low-risk patients to community optometrists, with proper guidance including when to be seen and when to escalate. This will free outpatient capacity.
- Enable multiprofessional education to upskill the regional workforce and create a network of glaucoma practitioners who can share learning and experience.
- Use Integrated Care Board (ICB) funding to increase third sector pastoral support.
Systematise and democratise the management of glaucoma data:
- Each patient should own their data.
- Establish a minimal data set and standards (e.g. open access, exchangeable systems).
- Use the same platform to explore changes in visual fields, and share this data across the network.
- Create and standardise systems for hospital-community data transfer using cloud platforms, ensuring compliance with GDPR.
- Link community and hospital systems, so that data captured remotely can join the central record.
NATIONAL RECOMMENDATIONS
At present, patients with glaucoma experience a postcode lottery, with wildly varying standards of care depending on where they live. To achieve greater equity of outcomes, we need national-level action, across three broad areas.
Establish a more unified approach to glaucoma care:
- Create a National Eye Strategy for Eye Health.
- Establish a patient awareness campaign.
- Invest in AI, neuroprotection and genetic studies.
- Create an anonymised national audit for glaucoma outcomes to improve care.
- Require that all data and images from instruments are open and conform to DICOM standards. This will ensure that the data can easily be read by a device-agnostic viewer, and are not limited to proprietary software.
Ensure that no regions or groups are left behind:
- Standardise glaucoma care, for instance ensuring that patients with cataracts at independent hubs can get access to minimally invasive glaucoma surgery (MIGS).
- Eliminate the postcode lottery and patchy provision of care.
- Getting It Right First Time (GIRFT) guidelines on glaucoma should reduce variations
- Ensure that national bodies are unified on strategy, approach and data.
- Create a national network of forums to share and exchange experiences and best practice. This should extend beyond the core glaucoma community to incorporate innovations and new ideas.
Support glaucoma care outside of the hospital system:
- Improve funding for primary care optometry, including tests and screening.
- Train optometrists and allied healthcare professionals (AHPs) to perform some of the key tasks: as well as better using the workforce, this will enable career progression.
- Improve access schemes in poor areas and ethnic minority communities.
Acting now to improve glaucoma care
If we don’t think about how we deliver improved glaucoma care to patients in the future now, many more patients could lose vision unnecessarily. For some, this will mean the end of a career; for others, the end of independent living. These costs are not simply personal. When a person loses their sight unnecessarily, society loses what they could have offered and the state inherits the costs – not just of late-stage treatment, but of lost productivity and growing demand on social care. These impacts are likely to be especially severe in deprived socio-economic groups.
The current system provides a great deal of expert, sensitive care. Yet many cases of glaucoma still go undiagnosed. According to The Lancet Global Health Commission on Global Eye Health, “most people living with glaucoma have not been diagnosed and are not receiving treatment.” Even in high-income countries like the UK, surveys indicate that over 50% of people with glaucoma have not been diagnosed, let alone received treatment. If we stick to the status quo, the result will be an ongoing failure to make the best use of our skilled and dedicated eye care professionals – and a quiet and inexorable loss of sight for thousands of people.
It is possible to do better, and doing so is largely a matter of unleashing the potential of healthcare professionals. Instead of spending hours chasing missing data, reviewing low-risk patients and firefighting problems, specialist ophthalmologists could be empowered to give time and attention to the growing number of complex glaucoma cases. Achieving this requires improving the entire ‘pipeline’ of glaucoma care.
Setting our sights on a better future
The glaucoma care system was always going to have to change thanks to the UK’s changing demography, the rise of technologies like genomics and AI, and the wider forces buffeting the NHS. When change is inevitable, it’s always best to be proactive: to decide what the future should look like and work towards it. Our vision of the future of glaucoma care aims to preserve all the things that are good about the current system, and simultaneously reform it so that in a decade’s time patients with glaucoma get even better care.
Systems change because someone tries something new, even something small and local. Every clinic that tests a new idea, every team that shares a tool: all can inspire the changes that follow.
“I think there is the potential, with sufficiently coordinated joined-up planning and thinking, for an amazing shift in what we do for the majority of glaucoma patients,” says Gus Gazzard at Moorfields Eye Hospital in London.
The glaucoma care system we need already exists in fragmentary form. The AI tools are being tested. New treatments are being developed. Care pathways are being redesigned.
“It’s probably one of the most innovative subspecialties, out of all the eye specialties at the moment, because we have so many new techniques,” says Nishani Amerasinghe at University Hospital Southampton.
What’s missing isn’t innovation: it’s momentum, consistency and nationwide commitment. As the science fiction author William Gibson famously said: “The future is already here – it’s just not very evenly distributed.”
What is needed is a quiet revolution by everyone involved in caring for patients with glaucoma, at every level: a consultant who streamlines one workflow, an optometrist who shares data differently, a team that tries a new approach to patient follow-up. That could be you. That could be today.
Read The Articles Here
Article 1: Introduction
A clear look at a better future for glaucoma care. Glaucoma is one of the most common causes of vision loss and blindness. More than 3% of people over 40 have glaucoma, and perhaps 10% of over-75s.
Article 2: Setting the Scene
A shared vision of the future of glaucoma care. Glaucoma patients and healthcare professionals have different perspectives on glaucoma care, but they share many of the same priorities.
Article 3: Artificial Intellegence
AI could help the highest-risk patients get glaucoma care . While artificial intelligence has many possible uses in glaucoma, its greatest potential is in identifying those at greatest risk.
Article 4: Sustainable Service Delivery
Ensuring the right patient is seen by the right person at the right time. How can the healthcare system ensure that every glaucoma patient is seen, while also maintaining empathic health professional - patient relationships.
Article 5: Innovative Treatments
The new cornucopia of treatments for glaucoma. From new types of pharmaceuticals to novel surgical approaches, there are now many more treatments available for glaucoma.
Article 6: Health Equality
Ensuring access to glaucoma care is truly equitable. Poor people and members of ethnic minorities often receive worse glaucoma care. Fixing these inequities requires a tailored approach.
Article 7: Patient Education and Engagement
People with glaucoma need clarity about their condition. Patients with glaucoma who are educated about their diagnosis are more likely to actively engage in their care and often have better outcomes.
Article 8: Conclusions and Recommendations
What if we got it right? The Future of Glaucoma Care in the UK. Shaping the future of glaucoma care at every level will not only improve patients’ lives but deliver lasting benefits for society.
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