Helen Lee, Prevention Manager at RNIB, tells us about a pilot study designed to test the efficacy of glaucoma case finding based in a GP Practice, targeting people of African and Caribbean descent.
Glaucoma is a chronic eye condition that, if left untreated, can lead to blindness. Glaucoma is the second most common cause of certifiable sight loss in the UK.
In the UK, the detection of glaucoma is opportunistic, with the majority of cases detected in high street optometry during a routine eye examination. An alternative approach, however, might be the introduction of a screening programme, where people are invited to be screened at regular intervals; similar to other programmes, such as the NHS diabetic eye screening programme.
The idea of a screening programme for glaucoma is not new. Nearly a decade ago a review of the clinical effectiveness and cost-effectiveness of screening for open angle glaucoma concluded that population screening is not cost-effective, but the targeted screening of high risk groups might be.
In the intervening years, there has been much debate about the merits of glaucoma screening, yet there remains no gold-standard evaluation of such a programme (ie a randomized control trial, or RCT). Reasons for the ongoing wait for robust evidence include a lack of data to properly quantify the costs of sight impairment and a continuing need to develop appropriate screening tests.
In an attempt to bridge the knowledge gap, RNIB partnered with City and Hackney PCT (as was), four GP practices in the London borough of Hackney, London School of Hygiene and Tropical Medicine, Moorfields Eye Hospital and the community in Hackney to develop a pilot glaucoma case-finding service based in a GP surgery.
The service ran from October 2012 to March 2013 and focused on members of the black African and Caribbean community, a group known to be 4 - 8 times more likely than white people to develop glaucoma. The service was located in one of the four participating GP practices and patients were invited to make an appointment for the check via a letter from their GP.
Just over 3000 people were invited to attend the service and nearly1 in 6 people invited attended an appointment. The service was universally well received, with over 95 per cent of people rating their experience as positive and nearly 90 per cent said the location of the service was convenient.
From a sight loss prevention perspective, the proportion of people checked who were subsequently diagnosed with glaucoma, or as glaucoma ‘suspect’, was 2.6 per cent. Approximately 1 in 10 people attending the service had never engaged with eye care services. Fewer than half the people with a known family history of glaucoma had been for an eye examination in the last year, the minimum re-examination interval for people over 40 with a family history of glaucoma.
What of the wider learning from the study? It is fair to say that significantly more resource was required than anticipated and thanks must go to the staff at the GP practices, in particular the host practice. Whether the set-up of the service is suitable for a large-scale screening programme – we used sessional optometrists and a series of gold-standard tests – also remains to be seen.
In 2014, the group leading much of the research on glaucoma screening in the UK reported that there is still not enough evidence to support a glaucoma screening RCT. The findings from our pilot case-finding study, released after the report, address several of the evidence gaps. The extent to which more data is needed on the economic cost of sight loss, as the authors suggest, is open to debate. One thing is for sure; the early detection and treatment of glaucoma must remain a priority for the UK.
For more information about the glaucoma case finding study described in this article and the findings from the research, visit our Knowledge Hub. The author of this Expert series article can be contacted at [email protected]
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