Recent investigations regarding the prevalence of glaucoma report that 1.86% of the US population over 40 years of age is affected. Based on 2000 census data, there are approximately 2.22 million cases of open-angle glaucoma in the United States.1 By 2020, the incidence of open-angle glaucoma among the population older than 40 years will increase an estimated 50%.1 This statistic translates to approximately 3.36 million patients with glaucoma who will require eye care in the next 15 years.
Not surprisingly, healthcare spending in the United States is on the rise, with a predicted increase from 16% of the gross domestic product in 2006 to 19.5% in 2017.2 Visual impairment taxes the healthcare system. The total medical costs for patients with any degree of visual loss are almost 50% higher than those of Medicare beneficiaries who have not lost vision.3 Among patients with end-stage glaucoma, the cost of pharmaceuticals, visual rehabilitation, and ophthalmologic care exceeded $2,000 per year in 2006.4 In 2003, the cost of blindness and visual impairment unrelated to eyes among the Medicare population was greater than $2 billion.5
As the number of patients with glaucoma and the cost of their healthcare have grown, the number of accredited fellowship-trained glaucoma specialists has gradually shrunk6 (Figure 1). Previous residency matching statistics from 2002 indicate that, of the 43% of residency graduates pursuing fellowship training, 15.1% were specializing in glaucoma. In 2007, 17 of 135 (12.6%) surveyed ophthalmology residents were pursuing a glaucoma fellowship.6 If the current downward trend in the number of glaucoma fellows accredited by the Association of University Professors of Ophthalmology continues, the patient-to-doctor ratio will grow.
By working together, optometrists and ophthalmologists can improve current patients' access to eye care as well as prepare for the impending upswing in the number of individuals with glaucoma. Collaboration between an optometrist and a glaucoma specialist in particular can provide patients with excellent clinical care and increase the volume of patients served by the practice. My experience is a case in point.
MY TRAINING
My optometric curriculum at the Pennsylvania College of Optometry in Elkins Park provided me with a preparatory, broad-based, working medical knowledge of subjects ranging from EKGs and neuroimaging to embryonic development and the most current theories in ophthalmic medicine. During my fourth year, I chose a combination of private practice- and hospital-based rotations that were heavily focused on the diagnosis and treatment of diseases of the eye and adnexa. I spent part of my fourth year with a retina specialist and in a Veterans Affairs Medical Center.
Upon graduation, I applied for and was offered a residency position at the Baltimore Veterans Affairs Medical Center. In this high-volume clinic, I became familiar with diagnostic techniques including gonioscopy, binocular indirect ophthalmoscopy, fluorescein angiography, perimetry, ultrasonography, and ocular photography. I was responsible for the daily care of patients and presented cases to attending physicians during weekly specialty clinics. The didactic portion (daily morning lectures and grand rounds) of my residency was at the Wilmer Eye Institute, where I also rotated through specialty clinics in cornea, LASIK, and contact lens (8 to 10 weeks each) alongside ophthalmology fellows. In addition, I worked with private practitioners in the community.
Nationally, as many as 20% of all optometry graduates undertake a 1-year residency program.7,8 The training is designed to provide residents with additional experience in a chosen area of specialty such as cornea, pediatrics, primary care, ocular disease, low vision, or contact lenses. Of the hundreds of accredited residency positions across the United States, just over 100 are titled Ocular Disease and meant to equip graduates with advanced training in the diagnosis, treatment, and management of ocular conditions and emergencies.8 All residency programs are accredited by the Optometry Residency Matching Service, but each is unique in the type of experience it will provide. Candidates are selected for consideration via a matching service (similar to ophthalmic residents) and then further evaluated on the basis of professional recommendations, grades, test scores, and an interview process. As part of their program, residents are often required to write and submit a paper of publishable quality and to take part in teaching students of optometry.
PUTTING THEORY INTO PRACTICE
The optometrist and ophthalmologist should work together closely on their first mutual cases in order to become familiar and comfortable with each other's clinical decisions and managerial styles. Excellent communication and careful charting help to ensure a healthy professional relationship.
After completing my residency, I joined the busy office of an established, fellowship-trained glaucoma specialist as an associate. Over the course of 1 year, we have forged a unique professional association that fulfills our patients' need for quality care and satisfies our clinical interests. My clinical responsibilities encompass diverse aspects of diagnosing and managing disease. My initial assessment includes taking a careful patient history, conducting a complete review of systems, and performing a thorough ocular examination (including a dilated fundus evaluation) to establish baseline findings. I rely not only on my observations and specialized clinical testing such as gonioscopy but also on technologic testing such as perimetry, diagnostic imaging, and pachymetry. I use this information to determine the type and severity of glaucoma as well as to rule out secondary syndromes (eg, neurological disorders).
I monitor patients on medical therapy for glaucoma to identify possible lapses in their compliance, new-onset allergies to drugs, and symptoms (eg, depression, sedation, shortness of breath, impotence) that may be associated with their medical regimen. I also watch carefully for uncontrolled IOP and disease progression, as evidenced by changes in the optic disc or visual field. The glaucoma specialist and I meet regularly to review any challenging cases for signs of disease progression. We reassess patients with deteriorating vision to determine when more aggressive management is warranted. The specialist follows patients with complicated glaucoma (ie, neovascular, pediatric) or failed filters, among others. He is responsible for planning and performing surgery as well as for making complex decisions. We collaborate on postoperative follow-up. My responsibility for co-managing surgical cases includes carefully tailoring patients' schedules of medication to encourage their recovery, monitoring a bleb until it matures, and determining when a bleb may fail.
In addition to clinical responsibilities, optometrists can participate in community services and research projects. For example, I serve as a subinvestigator on many national clinical research trials, work I find both interesting and rewarding. I have also provided routine eye examinations to the family members of our current glaucoma patients, and I have participated in glaucoma screenings in our community.
PROPOSING FUTURE COOPERATION
As the population of patients over 65 years of age grows and the number of glaucoma specialists shrinks, cooperation between optometrists and ophthalmologists offers an effective means of increasing patients' access to eye care and improving the quality of that care. A team approach will also help identify a larger number of patients whose glaucoma is as yet undiagnosed. Preventing visual loss should have a long-term positive impact on the cost of eye care in the United States.
Jennifer L. Stone, OD, is an associate in a private glaucoma practice in Baltimore. She also works part time at the Veterans Affairs Administration Medical Center. Dr. Stone may be reached at (410) 377-2422; jstone@glaucomaexpert.com.
