SLT delivery by non-medical ophthalmic practitioners could serve patients with glaucoma

Investigators explained that optometrists are now involved in the delivery of laser treatments in the UK Hospital Eye Service. Image credit: ©turbomotion046 – stock.adobe.com

Researchers from Moorfields Eye Hospital and the Institute of Ophthalmology at University College London have developed and delivered an education and training programme for the delivery of lasers, including selective laser trabeculoplasty (SLT) by non-medical ophthalmic practitioners. The training programme is based on medical education principles, is based on previous qualitative research into the role of ophthalmic practitioners in the delivery of laser treatments and is expected to have multidisciplinary benefits for ophthalmic healthcare. Investigators believe that by adhering to the programme protocols, SLT can be delivered safely.

Alex Delaney, MD, PhD, and colleagues discussed the potential for non-medical ophthalmic clinicians in the UK to deliver SLT at the European Glaucoma Society 2024 meeting in Dublin. Dr Delaney is from the Department of Ophthalmology, Royal Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom.

In a recent publication,¹ investigators explained that optometrists are now involved in the delivery of laser treatments in the Hospital Eye Service (HES), but there is no standardised national training framework for non-medical clinicians.

The argument for such a programme is supported by existing research findings. According to the authors, “SLT is as effective as eyedrops in controlling intraocular pressure (IOP)in eyes with open-angle glaucoma or ocular hypertension. Almost 70% of eyes remain drop-free for at least 6 years after primary treatment with SLT. SLT has been shown to delay the need for surgery to lower IOP. SLT is also cost-effective for the NHS and is now the first line treatment for glaucoma and ocular hypertension.”

Another argument is that NHS glaucoma services in the UK recently has been closely scrutinised because of cases of severe vision loss resulting from the inability to closely monitor progression^2,3 and more delays from COVID-19.⁴ A search for new, efficient, and safe models of care began that included management of glaucoma by appropriately trained non-medical professionals.^5-8

The programme and results

The proposed programme, designed by Moorfields Optometry Education, will comprehensively train ophthalmic healthcare professionals to competently deliver SLT including pre- and post-treatment care based on sound educational principles.

The course includes three stages: stage one, knowledge acquisition and demonstration of procedure gained from online asynchronous lectures and practical training days; stage two, work-based learning and assessment; and stage three, reflective practice that includes a self-audit and reflective statement composed at the end of training.

A total of 240 laser procedures were included in the audit. The investigators reported that the performance audit showed 100% compliance with procedures, which included a risks and benefits discussion, the consent procedure and the correct prescribed post-laser medication. The IOP was checked 1 hour after treatment in 99.6% of cases.

Regarding safety, one eye (0.4%) developed post-laser corneal haze and one eye (0.4%) developed cystoid macular oedema, both of which resolved with treatment and had no effect on vision; an IOP spike over 30 mmHg occurred in nine eyes (3.7%). No sight-threatening adverse events developed.

“Early results indicated that trained optometrists follow the relevant clinical protocols and deliver safe laser treatments. Despite an initial investment of time, trained optometrists can take on a significant clinical load, working autonomously. Further publications on the efficacy of optometrist-delivered SLT will follow, aiming to enrich the evidence base of non-medical ophthalmic laser delivery,” the investigators concluded.

References

1. Konstantakopoulou E, Varia J, Parmar J, et al. Optometrist-delivered selective laser trabeculoplasty in the HES – a training protocol and early service evaluation. Eye. 2024; published online May 3; https://doi.org/10.1038/s41433-024-03086-1

2. Foot B, MacEwen C. Surveillance of sight loss due to delay in ophthalmic treatment or review: frequency, cause and outcome. Eye. 2017;31:771–5.

3. National Patient Safety Agency. Preventing delay to follow-up for patients with glaucoma. NPSA/2009/RRR004. 2009. Available at https://www.ahpo.net/assets/ rrr004_supporting_information_glaucoma__final.pdf.

4. Jayaram H, Strouthidis NG, Gazzard G. The COVID-19 pandemic will redefine the future delivery of glaucoma care. Eye. 2020;34:1203–5.

5. The Royal College of Ophthalmologists. Commissioning Guide: ‘Glaucoma and Ocular Hypertension. London: Royal College of Ophthalmologists and the Clin- ical Council for Eye Health Commissions; 2016. Available at https:// www.rcophth.ac.uk/wp-content/uploads/2016/06/Glaucoma-Commissioning- Guide-Long-June-2016-Final.pdf.

6. The Royal College of Ophthalmologists. The way forward: glaucoma. 2017. Available at https://www.rcophth.ac.uk/standards-publications-research/the- way-forward/.

7. National Institute for Health and Care Excellence. Exceptional surveillance of glaucoma: diagnosis and management (NICE guideline NG81) – Surveillance report. 2019. Available at https://www.nice.org.uk/guidance/ng81/resources/ 2019-exceptional-surveillance-of-glaucoma-diagnosis-and-management-nice- guideline-ng81-pdf-8944833593797.

8. Healthcare Safety Investigation B. Lack of timely monitoring of patients with glaucoma. Healthcare safety investigation 2019/001. United Kingdom; 2020. Available at https://www.hsib.org.uk/documents/199/hsib_report_lack_timely_ monitoring_patients_glaucoma.pdf.