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05 Jun 2013

AMA President, Dr Steve Hambleton, said today that, in the interests of quality patient care, the Optometry Board of Australia must reverse its unilateral decision to allow optometrists to independently treat patients with chronic glaucoma without first making contact with an ophthalmologist.

Dr Hambleton said that the Optometry Board had failed to genuinely consult with ophthalmologists prior to and since its March 2013 decision to effectively expand the scope of practice of optometrists beyond their training.

“The Optometry Board of Australia has given the green light for optometrists to go it alone in managing patients with glaucoma and other serious eye conditions.

“They have made it possible for optometrists to commence treatment for patients with, or at high risk of developing, chronic glaucoma and to initiate therapy without reference to an ophthalmologist.

“The Board is out of step with the experts on best patient care for patients with glaucoma.

“National Health and Medical Research Council (NHMRC) Guidelines provide for optometrists to seek advice from ophthalmologists where the degree of diagnostic suspicion of glaucoma is high. 

“The Pharmaceutical Benefits Advisory Committee (PBAC) recognises the importance of optometrists confirming diagnoses of glaucoma with ophthalmologists and the need for the two health professions to work together to manage patients with glaucoma.

“Under the Pharmaceutical Benefits Scheme (PBS), patients with glaucoma can only have access to subsidised glaucoma medicines if the diagnosis is confirmed by an ophthalmologist and there is ongoing collaboration between the optometrist and ophthalmologist.

“The peak advocacy group, Glaucoma Australia, wants the previous collaborative care arrangements between optometrists and ophthalmologists for the detection and management of glaucoma to be maintained.”

Dr Hambleton said the AMA is also concerned with other aspects of Optometry Board Guidelines for Optometrists.

“For other eye conditions, such as ocular inflammation, the Optometry Board allows optometrists to treat ocular emergencies rather than refer patients to an ophthalmologist.

“And the Board only requires optometrists to consider referral for a specialist opinion for patients who may require long-term steroid use.

“In making these guidelines, the Optometry Board of Australia has failed to protect the interests of the Australian public in the detection and proper management of glaucoma and other serious eye conditions.

“If the Optometry Board does not heed the advice of the other health professionals who treat eye disease and revoke the new guidelines, the AMA believes that Health Ministers should instruct the Board to do so in the best interests of patients,” Dr Hambleton said.

Background:

According to the Glaucoma Australia website (http://www.glaucoma.org.au/):

  • glaucoma is the name given to a group of eye diseases in which the optic nerve at the back of the eye is slowly destroyed. In most people, this damage is due to an increased pressure inside the eye - a result of blockage of the circulation of aqueous, or its drainage. In other patients, the damage may be caused by poor blood supply to the vital optic nerve fibres, a weakness in the structure of the nerve, and/or a problem in the health of the nerve fibres themselves;
  • more than 300,000 Australians have glaucoma. While it is more common as people age, it can occur at any age. As our population becomes older, the proportion of glaucoma patients is increasing;
  • glaucoma is the leading cause of irreversible blindness world wide;
  • one in 10 Australians over 80 will develop glaucoma;
  • First degree relatives of glaucoma patients have an eight-fold increased risk of developing the disease;
  • at present, 50 per cent of people with glaucoma in Australia are undiagnosed;
  • Australian health care cost of glaucoma in 2005 was $342 million; and
  • the total annual cost of glaucoma in 2005 was $1.9 billion, with the total cost expected to increase to $4.3 billion by 2025.

Issues:

The Optometry Board guidelines are out of step with the NHMRC guidelines:

NHMRC Guidelines (page 83)

Optometry Board Guidelines

These guidelines encourage the establishment and nurturing of networks between primary health care providers, and between primary health care providers and ophthalmologists, to ensure best quality comprehensive care is provided to patients suspected of having, or diagnosed with glaucoma.

The Boards expects that optometrists managing patients with glaucoma will maintain regular communication with the patient’s general practitioner, ophthalmologist, physician or other health care practitioner.

If the degree of diagnostic suspicion of glaucoma is high however, the network should still be used for advice, and the appropriate decision may be a direct referral to a health care provider able to initiate treatment.

 

When a diagnosis of chronic glaucoma is made, or a patient is at high risk of developing the disease, optometrists … must:

Refer the patient for specialist assessment and advice about ongoing management;

OR

Develop a management plan that includes initiation of treatment and monitoring of the patient’s response.

The table below shows the anti-glaucoma medicines that the Optometry Board of Australia has listed for optometrists to prescribe independently, compared to other regulatory arrangements and the NHMRC Guidelines:

Medicine

PBS Listing

NHMRC Guidelines

Australian Register of Therapeutic Goods

Apraclonidine

Medical practitioners only

2nd line treatment

Listed

Betaxolol

Diagnosis confirmed by, and shared care with, an ophthalmologist

1st line treatment

Listed

Bimatoprost

Diagnosis confirmed by, and shared care with, an ophthalmologist

1st line treatment

Listed

Brimonidine

Diagnosis confirmed by, and shared care with, an ophthalmologist

2nd line treatment

Listed

Brinzolamide

Diagnosis confirmed by, and shared care with, an ophthalmologist

2nd line treatment

Listed

Carbachol

Not listed

3rd line treatment

Listed

Diprivefrin

Not listed

Not listed

Not listed

Dorzolamide

Diagnosis confirmed by, and shared care with, an ophthalmologist

2nd line treatment

Listed

Latanoprost

Diagnosis confirmed by, and shared care with, an ophthalmologist

1st line treatment

Listed

Levobunolol

Not listed

1st line treatment

Listed

Pilocarpine

Diagnosis confirmed by, and shared care with, an ophthalmologist

3rd line treatment

Listed

Timolol

Diagnosis confirmed by, and shared care with, an ophthalmologist

1st line treatment

Listed

Travoprost

Diagnosis confirmed by, and shared care with, an ophthalmologist

1st line treatment

Listed

Potential systemic side effects from beta-blocker eye drops (eg Timolol) include bronchospasm, hypotension, bradycardia, heart block, masked hypoglycaemia, adversely affected lipid profile, impotence, fatigue, depression, reduced exercise tolerance, fainting, confusion, and alopecia - none of which an optometrist would be expected to know anything about.


5 June 2013

CONTACT:         John Flannery                       02 6270 5477 / 0419 494 761
                          Kirsty Waterford                    02 6270 5464 / 0427 209 753


Published: 05 Jun 2013