Chapter 3: Development of a competency framework for optometrists with a special interest in glaucoma
3.3.2 Delphi: Round 2
There was a 93% (n = 14) completion and return rate for round 2. Tables 3.3 and 3.4 show the competency statements and corresponding scores at the end of round 2. The consensus view of the panel was that all 23 competencies were required for a role in glaucoma monitoring and treatment (Table 3.4).
For a role in diagnosis of glaucoma, 4 competencies (16, 17, 18 and 19 in Table 3.3) did not meet the criteria for consensus and were deemed not to be required for diagnosis. Four diagnostic competencies (10, 14, 15 and 22 in Table 3.3) were considered ‘borderline’ and were discussed at the subsequent workshop.
Table 3.3: Round 2 ratings for competencies required by optometrists involved in the diagnosis of glaucoma.
Competency Mean Rating
(9=essential)
% scoring
>= 6 1.The ability to take a comprehensive ophthalmic history in
a patient with diagnosed or suspected glaucoma, including the identification of ocular and systemic risk factors for glaucoma.
7.4 86.7
2.The ability to maintain clear, accurate and 7.9 86.7
contemporaneous clinical records of ophthalmic history, examination and results of clinical investigations in patients at risk of or with suspected glaucoma.
3.The ability to carry out an appropriate examination of the anterior segment of the eye in a patient at risk of, or with suspected glaucoma and to interpret relevant clinical signs.
8.3 93.3
4.The ability to perform the van Herick technique for the assessment of peripheral anterior chamber depth and to interpret the significance of the results.
8.1 93.3
5.The ability to perform a gonioscopic examination of the anterior chamber angle and to identify anatomical
structures, accurately grade the angle width and interpret the significance of clinical findings.
7.1 80.0
6.The ability to perform an assessment of central corneal thickness using appropriate instrumentation and to interpret the significance of the results.
7.6 86.6
7.The ability to recognise the signs and symptoms of a patient suffering from angle-closure glaucoma (or at risk of angle closure) and to refer the patient accordingly
(including the instigation of emergency treatment if necessary).
8.5 93.3
8. The ability to assess the optic nerve head by binocular indirect ophthalmoscopy and to detect the characteristic features of glaucomatous optic neuropathy,
8.9 93.3
9. An understanding of supra-threshold perimetric techniques used in the assessment of a patient with suspected glaucoma including test strategies used, sources of error, interpretation of results and the recognition of glaucomatous field loss.
8.4 93.3
10. An understanding of the use of threshold perimetric techniques for the assessment of a patient with manifest glaucoma including test strategies used, sources of error and artefact, and the ability to detect progression of disease.
6.7 66.7
11. An understanding of the imaging techniques used to 6.5 73.3
assess the optic nerve head and retinal nerve fibre layer and the ability to interpret the results of such
investigations.
12. The ability to differentially diagnose glaucoma through an interpretation and integration of the results of clinical examination and the results of any further investigative techniques.
8.3 93.3
13. The ability to detect and appreciate the significance of concurrent pathology in the management of glaucoma.
7.5 93.7
14. The ability to recognise the indications for treatment in glaucoma, the concept of target pressures and risk factors for disease progression.
7.2 59.9
15. The ability to detect a change in clinical status (e.g.
visual field status, intra-ocular pressure, assessment of anterior or posterior segments).
6.5 66.7
16. The ability to monitor the response to treatment and modify the management plan or consult a more
experienced colleague if necessary.
4.1 33.3
17. An understanding of time-frames for follow-up of patients taking into account local preferences, risk of progression, and patient related factors (age, concurrent disease etc).
4.9 53.3
18. Knowledge of the pharmacology, cautions, contraindications, interactions and side effects of anti-glaucoma medication.
4.9 53.3
19. Knowledge of the surgical management of the glaucomas including indications for surgery, surgical techniques, complications and post-operative evaluation.
3.8 40.0
20. An awareness of one’s own limitations and the ability to make clinical decisions based on the needs of the patient.
8.3 93.3
21. The ability to operate within local protocols for the detection and/or management of glaucoma.
8.1 93.3
22. The ability to help patients make informed choices about their management and to check their understanding of and commitment to their management and follow-up.
6.1 60.0
23. The ability to counsel patients regarding risks of blindness associated with glaucoma, risk to family members, potential impact of the disease on lifestyle (including driving) and provide information on available sources of help, counselling and support.
7.2 80.0
Table 3.4: Round 2 ratings for competencies required by optometrists involved in the monitoring and treatment of glaucoma
Competency Mean Rating
(9=essential)
% scoring
>= 6 1. The ability to take a comprehensive ophthalmic history
in a patient with diagnosed or suspected glaucoma, including the identification of ocular and systemic risk factors for glaucoma.
8.6 93
2.The ability to maintain clear, accurate and
contemporaneous clinical records of ophthalmic history, examination and results of clinical investigations in patients at risk of or with suspected glaucoma.
8.6 93
3. The ability to carry out an appropriate examination of the anterior segment of the eye in a patient at risk of, or with suspected glaucoma and to interpret relevant clinical signs.
8.7 100
4. The ability to perform the van Herick technique for the assessment of peripheral anterior chamber depth and to interpret the significance of the results.
7.6 86
5. The ability to perform a gonioscopic examination of the anterior chamber angle and to identify anatomical
structures, accurately grade the angle width and interpret the significance of clinical findings.
7.8 86
6. The ability to perform an assessment of central corneal thickness using appropriate instrumentation and to
interpret the significance of the results.
8.1 86.6
7. The ability to recognise the signs and symptoms of a patient suffering from angle-closure glaucoma (or at risk of
7.9 100
angle closure) and to refer the patient accordingly (including the instigation of emergency treatment if necessary).
8. The ability to assess the optic nerve head by binocular indirect ophthalmoscopy and to detect the characteristic features of glaucomatous optic neuropathy.
9.0 100
9. An understanding of supra-threshold perimetric techniques used in the assessment of a patient with suspected glaucoma including test strategies used, sources of error, interpretation of results and the recognition of glaucomatous field loss.
7.9 86
10. An understanding of the use of threshold perimetric techniques for the assessment of a patient with manifest glaucoma including test strategies used, sources of error and artefact, and the ability to detect progression of disease.
9.0 100
11. An understanding of the imaging techniques used to assess the optic nerve head and retinal nerve fibre layer and the ability to interpret the results of such
investigations.
8.1 86
12. The ability to differentially diagnose glaucoma through an interpretation and integration of the results of clinical examination and the results of any further investigative techniques.
8.6 100
13. The ability to detect and appreciate the significance of concurrent pathology in the management of glaucoma.
8.0 100
14. The ability to recognise the indications for treatment in glaucoma, the concept of target pressures and risk factors for disease progression.
8.6 100
15. The ability to detect a change in clinical status (e.g.
visual field status, intra-ocular pressure, assessment of anterior or posterior segments).
9.0 100
16. The ability to monitor the response to treatment and modify the management plan or consult a more
experienced colleague if necessary.
9.0 100
17. An understanding of time-frames for follow-up of 8.9 100
patients taking into account local preferences, risk of progression, and patient related factors (age, concurrent disease etc).
18. Knowledge of the pharmacology, cautions, contraindications, interactions and side effects of anti-glaucoma medication.
8.6 100
19. Knowledge of the surgical management of the glaucomas including indications for surgery, surgical techniques, complications and post-operative evaluation.
8.1 100
20. An awareness of one’s own limitations and the ability to make clinical decisions based on the needs of the patient.
9.0 100
21. The ability to operate within local protocols for the detection and/or management of glaucoma.
8.9 100
22. The ability to help patients make informed choices about their management and to check their understanding of and commitment to their management and follow-up.
8.6 100
23. The ability to counsel patients regarding risks of blindness associated with glaucoma, risk to family members, potential impact of the disease on lifestyle (including driving) and provide information on available sources of help, counselling and support.
8.6 100
3.3.3 Workshop
All Delphi panel members attended the workshop, at which borderline competencies were discussed and consensus reached regarding their inclusion. Competencies 9 and 10 were condensed into a single statement. One focus of the workshop discussion was on applanation tonometry. Although applanation tonometry is a GOC entry level competency for registration as an optometrist, the panel felt that the specific competency statement relating to tonometry needed further precision and the revised statement ‘The ability to accurately measure intraocular pressure using a slit-lamp mounted Goldmann applanation tonometer and the ability to analyse and interpret the results’ was added to the framework (new competency statement 8). The framework agreed following the workshop contained 19 competencies for glaucoma diagnosis and 7 further competencies for monitoring and treatment.