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Thread: Glaucoma tests ..

  1. #1
    Grand Master sundial's Avatar
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    Glaucoma tests ..

    Two months ago during a routine Specsavers eye test, the optometrist beckoned me to another part of the examination dept. to wait for a glaucoma test. Another technician then commenced the glaucoma 'Air Puff' (AP) test using an AP tonometer. She had a puzzled look on her face after considering the results and beckoned me to another AP tonometer where the test was repeated. With an even more puzzled look on her face she then said, "I need to speak to my colleague." She then reappeared with the senior optometrist who suggested the test needed repeating … for a third time. Following the third test the optometrist announced, "Glaucoma test results indicate a too high I.O.P. … intraocular pressure … you have glaucoma and need a referral to an ophthalmologist which we will arrange via your GP at your local medical practice. I thanked the optometrist and was then introduced to a Specsavers' technician who assisted me to choose and order new glasses.

    Thus followed a worrying 8 weeks before yesterday's earliest available appointment with an Anglia Community Eye Services (ACES) ophthalmologist. Yesterday's tests did not include an AP tonometer test but I had four other tests / examinations including one using a different type of tonometer.

    Following the opthalmologist's examinations he advised, "You do not have glaucoma … so please do not concern yourself about any eye defects. Your optic nerve is healthy and shows no signs of deterioration … and drainage is fine. The IOP is a little on the high side but of no concern … it's within the normal range. The 'air puff' test is often inaccurate and gives 'too high' readings. As a precautionary measure, because there is a glaucoma history in your family, we'll see you in 6 months time … but there really is nothing to worry about … no treatment or drops required."

    What a relief after two months of worry wondering if I'll still be able to use a camera in a few years time. One elderly aunt became partially sighted in her 90s due to glaucoma.

    The question arises as to whether Specsavers is using the most up to date and reliable test equipment. From what I've read there are better test procedures available and they're not 'rocket science' i.e. can be used by optometrists in high street opticians. I'm grateful for the more thorough ophthalmologist's examination but it was not really necessary .. and likely cost the NHS a pretty penny or two.

    dunk
    "… but the greatest gift the railways give to us is the proper treatment of time." John Betjeman , BBC Home Service radio broadcast 4 July 1940.

  2. #2
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    My wife's mum had glaucoma so it was always on my wife's optician's radar when she had her regular eye tests. She was eventually referred to an ophthalmologist for a possible opacity affecting her vision. She actually had quite severe glaucoma - it seemed as though the puff test had underestimated her IOP's and possibly on several occasions. It has taken quite a while testing various combinations of eye drops plus laser surgery to get her stabilised.

    It's a worrying condition so very pleased to hear that you're ok dunk.

    ATB

    Jon

    Sorry - to your point about reliability of the puff test, it clearly isn't as reliable as one would want. As for installing the equipment used in the hospital, I expect there might be a cost element as well as training?
    Last edited by JonRA; 17th May 2019 at 15:58.

  3. #3
    Grand Master hogthrob's Avatar
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    Glad to hear that you're OK. Whilst what happened is regretable, I supopse it's better than glaucoma being undetected.

  4. #4
    I should chime in here since I'm an optometrist and practice owner in sunny old Essex. The 'air puff' test (or, more correctly non-contact tonometer) is notoriously unreliable and prone to erratic results relating to patient anxiety and diurnal variation. I use a more modern form of tonometry called rebound tonometry which tends to be more comfortable for the patient, and hence more accurate. It also depends on interpretation of the user - Specsavers tend to outsource as much of the examination to ancillary staff to cut costs so you will always get a higher false positive rate with them.

    We have an Enhanced Service Scheme through the NHS operating in my area which is designed to triage out unnecessary referrals to the already over-stretched hospital eye service. Specsavers are notorious for over referring as more thorough patient care takes up chair time (better spent flogging specs in their view!).

    In short, next time you need an eye examination pop down and see me! Just don't get me started on watches otherwise I'll start running horrendously late!

  5. #5
    Grand Master sundial's Avatar
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    Quote Originally Posted by JonRA View Post
    My wife's mum had glaucoma so it was always on my wife's optician's radar when she had her regular eye tests. She was eventually referred to an ophthalmologist for a possible opacity affecting her vision. She actually had quite severe glaucoma - it seemed as though the puff test had underestimated her IOP's and possibly on several occasions. It has taken quite a while testing various combinations of eye drops plus laser surgery to get her stabilised.

    It's a worrying condition so very pleased to hear that you're ok dunk.

    ATB

    Jon

    Sorry - to your point about reliability of the puff test, it clearly isn't as reliable as one would want. As for installing the equipment used in the hospital, I expect there might be a cost element as well as training?
    Quote Originally Posted by hogthrob View Post
    Glad to hear that you're OK. Whilst what happened is regretable, I supopse it's better than glaucoma being undetected.
    Ophthalmologist also advised the test results have to be considered in conjunction with cornea thickness measurement. A thick cornea can result in an unreliable too high reading; a thinner cornea can result in an unrealistic too low IOP reading. My cornea was thickness was measured yesterday. I've no idea if the optometrist's equipment measured the cornea thickness.

    dunk
    "… but the greatest gift the railways give to us is the proper treatment of time." John Betjeman , BBC Home Service radio broadcast 4 July 1940.

  6. #6
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    Good to hear that more accurate equipment is available outside of hospital and that your area, pjsayer, is taking a strategic approach to service provision.

    I will try to find a local optician with the more accurate equipment.

    ATB

    Jon

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  7. #7
    Grand Master sundial's Avatar
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    Quote Originally Posted by pjsayer View Post
    I should chime in here since I'm an optometrist and practice owner in sunny old Essex. The 'air puff' test (or, more correctly non-contact tonometer) is notoriously unreliable and prone to erratic results relating to patient anxiety and diurnal variation. I use a more modern form of tonometry called rebound tonometry which tends to be more comfortable for the patient, and hence more accurate. It also depends on interpretation of the user - Specsavers tend to outsource as much of the examination to ancillary staff to cut costs so you will always get a higher false positive rate with them.

    We have an Enhanced Service Scheme through the NHS operating in my area which is designed to triage out unnecessary referrals to the already over-stretched hospital eye service. Specsavers are notorious for over referring as more thorough patient care takes up chair time (better spent flogging specs in their view!).

    In short, next time you need an eye examination pop down and see me! Just don't get me started on watches otherwise I'll start running horrendously late!
    Very interesting … a not too far trip to Essex could have saved me 8 weeks worry and internet glaucoma research.

    dunk
    "… but the greatest gift the railways give to us is the proper treatment of time." John Betjeman , BBC Home Service radio broadcast 4 July 1940.

  8. #8
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    Could be worse. I had an iridotomy due to narrow angle and now have annual hospital checks. At the last one the doctor at the time decided the pressure was too high and so referred me to the specialist. After two months waiting and shitting myself expecting to have lens replacement the specialist said it was all fine and within the healthy range. My optician correctly referred me in the first place btw for the condition.

  9. #9
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    Quote Originally Posted by pjsayer View Post
    I should chime in here since I'm an optometrist and practice owner in sunny old Essex. The 'air puff' test (or, more correctly non-contact tonometer) is notoriously unreliable and prone to erratic results relating to patient anxiety and diurnal variation. I use a more modern form of tonometry called rebound tonometry which tends to be more comfortable for the patient, and hence more accurate. It also depends on interpretation of the user - Specsavers tend to outsource as much of the examination to ancillary staff to cut costs so you will always get a higher false positive rate with them.

    We have an Enhanced Service Scheme through the NHS operating in my area which is designed to triage out unnecessary referrals to the already over-stretched hospital eye service. Specsavers are notorious for over referring as more thorough patient care takes up chair time (better spent flogging specs in their view!).

    In short, next time you need an eye examination pop down and see me! Just don't get me started on watches otherwise I'll start running horrendously late!
    Sorry chap but I'll take issue with the "notoriously unreliable" statement. There are plenty peer reviewed studies that show there are no statistical differences between NCT (non contact air puff) and goldmann tonometry. There is no reason to say that it is not an appropriate instrument for screening the general public. Rebound tonometry hasn't been shown to be any more reliable, or any less for that matter, its just different. Diurnal variation is a function of the patient not the instrument.
    I'd take issue with your statement that more comfortable means more accurate too. Bear in mind the measurement is taken before the patient knows about it and hence reacts. Yes some people show an increase after the first reading as a result of the method but not many in my experience.
    As a result of NICE guidelines a few years ago plenty of areas now have a secondary refinement procedure rather than a first hospital appointment and yes these always require Goldmann tonometry which remains the gold standard. Whether it should be is another matter entirely. I do a few of these each week and don't find a huge difference between NCT and goldmann.
    There are good and bad professionals in all walks of our (or any) profession but Id hope no practice will refer off the back of purely IOPs except into secondary services as they are required to. Interpretation is important as you say but it will be the qualified staff doing this even if the don't take the readings themselves. As I'm sure you know there is no great skill in getting the readings. If there are high false positives its the optoms at fault but it won't take any less time to achieve it. I'm not advocate of the jolly green giant but lets not tar them all with the same brush hey.

    For the general public in primary care NCT is entirely appropriate as long as it is accompanied by the usual companion tests and all considered appropriately before a referral is made.

    The OPs experience sounds awful and entirely inappropriate terminology was used as was pointed out by the medics. No form of tonometry alone has a great sensitivity for glaucoma diagnosis and certainly you'd want an OCT done before making any such statement.
    Last edited by DavidL; 17th May 2019 at 23:12.

  10. #10
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    I'd agree with David on this one. For routine screening, nct is more than adequate. It seems as though the interpretation/terminology used following the exam is the problem.

    As an aside, I've told patients before that I'm referring to be investigated for the possibility of having glaucoma etc, only to receive a phonecall later that day from a concerned spouse or relative, and the patient has told them I've definitively diagnosed said condition.

    I think that sometimes, when receiving news like this, our mind starts to race with the potential implications, and we miss some further information that's being given.



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  11. #11
    Shit I just read this thread how very worrying I cannot believe such a reputable chain would be so incompetent glad it was all ok in the end.

  12. #12
    Grand Master sundial's Avatar
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    Quote Originally Posted by WarrenVrs View Post
    I'd agree with David on this one. For routine screening, nct is more than adequate. It seems as though the interpretation/terminology used following the exam is the problem.

    As an aside, I've told patients before that I'm referring to be investigated for the possibility of having glaucoma etc, only to receive a phonecall later that day from a concerned spouse or relative, and the patient has told them I've definitively diagnosed said condition.

    I think that sometimes, when receiving news like this, our mind starts to race with the potential implications, and we miss some further information that's being given.



    Sent from my ONEPLUS A6003 using Tapatalk
    The reason I was so concerned was the fact that the AP tonometer test was conducted three times on two different machines … and the technician had a very puzzled expression on her face when she beckoned me to the second adjacent AP tonometer … and her expression did not change after the second test … or the third test … as if all the readings were excessively abnormal. No plans to revisit Supersavers in future.

    dunk
    "… but the greatest gift the railways give to us is the proper treatment of time." John Betjeman , BBC Home Service radio broadcast 4 July 1940.

  13. #13
    AS I understand it someone can have a high IOP w/o having glaucoma so rather strange for the optometrist to declare that OP had this condition.

  14. #14
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    I hate the “puff machine”, last year at my eye test I agreed to a new rest or as it turned out a scan, the opticians now have a picture of my eyes from the side, all very clever and I don’t pretend to understand it but the picture looked impressive and it means although all is well at this time it sets a standard for the future, next time I’m passing there I’ll ask what the test is called and post up so you all can google it and get an accurate explanation.
    Good to hear the OP got an all clear.

  15. #15
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    Quote Originally Posted by Pitfitter View Post
    I hate the “puff machine”, last year at my eye test I agreed to a new rest or as it turned out a scan, the opticians now have a picture of my eyes from the side, all very clever and I don’t pretend to understand it but the picture looked impressive and it means although all is well at this time it sets a standard for the future, next time I’m passing there I’ll ask what the test is called and post up so you all can google it and get an accurate explanation.
    Good to hear the OP got an all clear.
    It's an oct scan.

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  16. #16
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    Quote Originally Posted by WarrenVrs View Post
    It's an oct scan.

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