We know that our professional role may be different in some countries, and one example is the Orthoptist activity relating to Glaucoma care (ex.: Glaucoma screening and stable Glaucoma management).
In Portugal Orthoptists are valuable members of a multi-disciplinary team and we have to cope with the evolution of Ophthalmology/Orthoptics and growth of the Eye departments by reaching beyond Orthoptic traditional role. However, at the moment I feel that we cannot give a proper response to our Glaucoma patients.
And so I looked to get the most of the IOA Exchange program: a great new experience and learn a little about the role of the Orthoptist in Glaucoma care.
I made a two weeks visit to Frimley Park Hospital (United Kingdom). This is a hospital-based clinic that serves patients in Surrey, Berkshire and Hampshire counties in southern England, and also is a reference treatment center for Age Related Macular Degeneration. Frimley Park Hospital NHS Foundation Trust was one of just two runners up announced as Hospital Trust of the Year by Dr Foster Intelligence, recognised as one of the most important independent assessors of quality in NHS hospitals (published on 3rd December 2012 in Dr Foster Hospital Guide 2012).
The Eye Department has a team of 8 Orthoptists, led by Lorraine North (Consultant Orthoptist). I was able to meet and observe work of diverse members of the staff that included Ophthalmologists, Orthoptic assistants, Optometrists, specialized eye Nurses and Ophthalmic Photographers. It also impressed me how well equipped they are, with some of the most recent technology used for diagnosis and treatment at their disposal.
The visit was really interesting because the eye department offered me observation in many interesting activities, and I always felt great support from all my colleagues. I was allowed to attend clinics related to Orthoptics and Pediatric Ophthalmology/Strabismus, Glaucoma, Retina and Refraction. I also attended eye exams in which Orthoptists are involved such as Optical Coherence Tomography, Fluorescein Angiography and Visual Fields.
While attending the Orthoptic clinics I realized how important the Orthoptists are to monitor the vision of the pediatric population, as well as in the management of children who have vision problems. Usually, if it is the first consult, the children are observed first by the Orthoptist and afterwards by the Ophthalmologist. If we are dealing with an Amblyopia or only a refraction problem, the Orthoptic department manages the case. One of the Orthoptists, Wendy Hockney, is trained in Retinoscopy and, although it is not usual in the United Kingdom to see Orthoptists refracting, she does a Refraction clinic which is very useful to the management of these patients. If there is squint or other conditions, the Orthoptists and the Ophthalmologists usually manage the case together. The Orthoptic department is also responsible for some vision screening events in the community.
I was able to spend some time with Mr Govan, a consultant Ophthalmologist, in his strabismus/ocular motility clinic. As an Orthoptist it was most gratifying to learn the surgical perspective from him, and to see how he and the Orthoptists interact as a team.
The Retina clinic was probably one of the busiest, as the number of patients with pathologies such as AMD or Diabetic Retinopathy continues to rise. The treatment with anti-VEGF has helped these patients a lot, but it also obligates the Eye Department to make a greater effort in order to give a proper response. I have visited the Retina and the stable-VEG clinics, as well as the OCT room, which gave me the perception of the amount of patients that the department needs to monitor and the organization that is necessary to do it. The patients are scanned in the OCT room first and are evaluated by the Ophthalmologist right after it. If he decides that the patient needs an injection, it is done right away in a specific sterile room, so that the treatment can be as effective as possible. This has also given me the opportunity to observe one of these procedures.
Regarding the Glaucoma field, I had set an objective and expectative for what I wanted to see and learn. I expected to see Orthoptists screening patients for Glaucoma, and with an important role in the management of those who had the disease or had a greater risk of developing it, working closely with the Ophthalmologist. And that was exactly what I have found!
There were three different Glaucoma clinics: the Glaucoma Assessment clinic, the Stable Glaucoma clinic, and Glaucoma (consultant) clinic.
Normally people check their Intraocular Pressure at optician, and when the measurement is above 21mmHg (non-contact tonometer), it needs to be reported to the GP, who refers a patient to the hospital. All these patients go through the Glaucoma Assessment clinic in which a full examination is performed by Orthoptists, including Visual Fields, HRT (Heidelberg Retinal Tomography), Visual Acuity, Intraocular Pressure (Goldmann tonometer), Pachymentry, van Herick angle grading and if necessary gonioscopy (done by an ophthalmologist). The results are analyzed later by the Glaucoma consultant, who will decide whether the patient is discharged or needs another appointment (they estimate that roughly 80% of the patients are discharged). The Glaucoma Assessment clinic may be carried out fully by the Orthoptist, however some cases may determine that the patient needs to start treatment right away, which requires cooperation with an Ophthalmologist.
In the stable Glaucoma clinic the Orthoptists have to monitor and manage patients diagnosed with Glaucoma or Ocular Hypertension but their pressures, visual field defects and optic nerve cupping are stable. Similarly to the Glaucoma Assessment clinic, the teamwork between Orthoptist and Ophthalmologist is important in the case of a therapeutic change being needed.
Colonel Griffiths was the Glaucoma consultant, and I was able to sit with him in his clinic a few times. He observes all the patients that have confirmed to be Glaucoma suspects by the Glaucoma Assessment clinic, those who were monitored in the Stable Glaucoma clinic but are no longer stable or are not seen by the consultant for 2 years, as well as all the regular Glaucoma patients. He seemed to be very supportive of the surgical approach for keeping the IOP under control rather than wasting a lot of time searching for eye drops combinations that can provide the same effect. It was a very important and gratifying experience for me, especially because I was able to participate in the observation and discussion of plenty of cases. Lorraine also does a Glaucoma clinic, working closely with Colonel Griffiths, with high level of autonomy but complementary at the same time.
I now hope to use this knowledge to become a better and more complete Orthoptist, but above all I would like that this experience could help me to provide a better care to our patients here in Portugal. In the specific area of Glaucoma I am sure that there is important work that Orthoptists can start developing, which certainly would make a change for better.
I have learned a lot and enjoyed this visit very much, and I am grateful to everyone that were a part of this experience, but I would I like to leave my special thanking to Katherine Fray from IOA for all the support and Lorraine North for opening the doors of the Orthoptic department for me, as well as all the colleagues (Eleanor, Danielle, Wendy, Nikki, Jackie, Emma and Orna) that helped and supported me during this visit.
It was an excellent experience that I recommend to every Orthoptist and that I would be very happy to repeat.
Luís Martins
https://www.internationalorthoptics.org/fileadmin/user_upload/Portugal_UK.pdf
