When should an optometrist refer a patient for glaucoma?

At the end of an initial visit with a new patient, an optometrist will be alerted that the patient may be at risk for glaucoma by tonometry, ophthalmoscopy and by visual fields. Yes, visual fields.

The visual field, either by frequency doubling or the traditional white on white static techniques has quickly become a standard part of the optometric examination. While the first visual field may be atypical or even abnormal, the iterative intellectual process follows the traditional optometric paradigm of collecting sufficient information before concluding that (a) the atypical finding is not indicativie of a disease or (b) there is sufficient rationale for more testing.

In the model of optometry that I had posted previously, the optometrist may either follow the “detect and refer” model and immediately refer the patient or attempt to discern whether there are additional findings that might further define this as a patient with a risk for glaucoma or one who has a high likelihood or even a diagnosis of glaucoma.

To many ophthalmologists, they may see or even wish that optometrists would immediately refer any patient who demonstrates any risk for glaucoma and I would agree that probably the majority of optometrists would do that.

However, in the last ten or even twenty years, optometrsists have either gained the legislative privilege and educational preparation to diagnose and manage most of the common forms of glaucoma. The ophthalmologist might find it heartening then, that a referral from a more progressive optometrist might not be a false positive referral (one that is assumed to have glaucoma but doesn’t require medical treatment). In these cases, the optometrists will liekly refer a patient who may have an advancing form of glaucoma that may not be amenable to a single or even dual topical therapy.

It is sometimes a difficult choice for some optometrists to choose which ophthalmologist to send a patient. Although it may be optimal to refer the patient to the best qualified medical practitioner, there might be alternative factors that dictate the referral.

These will be covered in a later post, but it is sufficient to say that an ophthalmologist who openly or covertly suggests that a particular optometrists should have sent the patient to them simply on the basis that the optometrist doesn’t have the capability to treat and manage a patient will not likely be high on the list of a referral regardless of the skill of that ophthalmologist.

Most, if not all optometrists are quietly proficient and even humble about their role in glaucoma management. This approach has helped promote optometric/patient relationships where the pace of a traditional ophthalmologic office might not provide that kind of atmosphere. Respect runs both ways. They will respect ophthalmologists who aren’t overly condescending. They would hope that they will be treated like a colleague who welcomes pointers and clues to better care for their patients. Respect after all, is one of the few human qualities that produces many returns for both the optometry and ophthalmology.