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 comanaged by institutionally trained optometrists and glaucoma specialists at the University of California San Francisco.
Design: Retrospective cohort study.
Participants: Patients with glaucoma suspect or stable glaucoma diagnoses from 2016 to 2023.
Methods: Patients were comanaged 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 retinal nerve fiber layer (RNFL) thickness.
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) whereas the 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 rereferred to glaucoma specialists, with 43 (11.0%) returning to comanagement after evaluation or treatment. Alternate care patients saw both optometrists and glaucoma specialists at a median rate of once per year. Transfer care patients saw optometrists at a median rate of twice per year and none by glaucoma specialists. In multivariable analysis, escalation was associated with older age (odds ratio [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). Care pathway assignment was not significantly associated with treatment escalation.
Conclusions: A well-defined and closely monitored comanagement model can maintain patient safety and glaucoma stability over 5 years with improved resource allocation and reduced utilization of glaucoma specialists.
Financial disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Keywords: Comanagement; Glaucoma; Optometry.
Published by Elsevier Inc.