Ophthalmologist and Optometrist Co-management Model for Glaucoma: Outcomes from a Single Tertiary Care Health Center.

PURPOSE

The growing demand for eye care poses significant challenges to the effective management of patients with glaucoma. This study evaluated long-term clinical outcomes of patients with glaucoma co-managed by institutionally trained optometrists and glaucoma specialists at UCSF.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients with glaucoma suspect or stable glaucoma diagnoses from 2016-2023.

METHODS

Patients were co-managed by glaucoma specialists and optometrists with postgraduate institutional glaucoma-specific training via either "alternate care" (alternating glaucoma specialist and optometrist visits) or "transfer care" (optometrist visits only) for up to 5 years of follow-up. Generalized linear models were used to assess long-term changes in clinical parameters.

MAIN OUTCOME MEASURES

Changes in intraocular pressure (IOP), best-corrected visual acuity (BCVA), medications, Humphrey visual field (HVF), and OCT retinal nerve fiber layer (RNFL).

RESULTS

The study included 391 patients (775 eyes), with 136 (34.8%) in alternate care and 255 (65.2%) in transfer care. The most common diagnoses were glaucoma suspect (51.2%) and primary open-angle glaucoma (POAG, 36.0%). No significant changes were observed in BCVA (p=0.34), IOP (p=0.18), medications (p=0.11), or RNFL (p=0.65) while mean deviation of HVF improved (p=0.003) over 5 years among both groups. Overall, 132 eyes (17.0%) required treatment escalation: 81 (10.5%) needed increased medications, 34 (4.4%) underwent glaucoma-related laser treatment, and 17 (2.2%) had incisional surgery. Among all eyes, 56 (14.3%) were re-referred to glaucoma specialists, with 43 (11.0%) returning to co-management after evaluation or treatment. Alternate care patients saw both optometrists and glaucoma specialists a median of once per year while transfer care patients saw optometrists a median of twice per year and none by glaucoma specialists. In multivariable analysis, escalation was associated with older age (OR 1.30 per decade; 95% CI 1.04-1.63; p=0.02), POAG vs suspect (OR 2.99; 95% CI 1.59-5.65; p<0.001), and higher baseline IOP (OR 1.18 per mmHg; 95% CI 1.07-1.30; p=0.01). The care pathway of each patient was not significantly associated with treatment escalation.

CONCLUSION

With appropriate training, a well-defined and closely monitored co-management model can maintain patient safety and glaucoma stability over five years with improved resource allocation and reduced utilization of glaucoma specialists.