WRITERS Dr Margaret Lam and Dr Colin Clement

Glaucoma care increasingly involves collaboration between ophthalmology and optometry. In this article, Dr Margaret Lam explores the opportunities to improve outcomes with Sydney ophthalmologist, Dr Colin Clement.

Glaucoma care is undergoing rapid modernisation. Advances in imaging, artificial intelligence (AI), and minimally invasive surgery are enabling earlier detection, more precise risk assessment, and safer long-term management. At the same time, shared-care models between optometrists and ophthalmologists are strengthening, supported by clearer referral pathways, better diagnostic capability, and a growing culture of coordinated care.

Q. How has glaucoma diagnosis and management evolved in recent years?

Over the past decade, glaucoma diagnosis and management have undergone significant transformation, driven by advances in imaging, analytics, and therapeutics. The overarching trend is a shift toward earlier detection, more individualised risk assessment, and safer, more targeted treatment options.

Diagnostic capability has expanded markedly with high-resolution structural imaging. Modern spectral-domain and swept-source optical coherence tomography (OCT) technologies provide precise measurement of the retinal nerve fibre layer, macular ganglion cell complex, and optic nerve head architecture, allowing clinicians to detect subtle changes long before functional loss appears. At the same time, visual field testing has improved through faster, more reliable thresholding strategies and the emergence of portable platforms that enable home-based monitoring. These innovations support earlier detection, more continuous assessment of progression, and improved access for rural and remote communities.

AI is emerging as an adjunct, particularly in interpreting optic nerve and OCT data. Deep-learning algorithms can identify glaucomatous damage with accuracy comparable to expert clinicians, assist in risk stratification, and flag patients who require urgent evaluation. Although AI is not yet mainstream in clinical practice, and is not a replacement for clinical judgement, it is being increasingly integrated into screening workflows and shared-care models.

Management has similarly evolved. Minimally invasive glaucoma surgery (MIGS) has reshaped the surgical landscape, offering safer procedures that lower intraocular pressure (IOP) with fewer complications and faster recovery. These are increasingly used in combination with cataract surgery, or as a step prior to traditional trabeculectomy or tube surgery. An exciting emerging development is sustained-release drug delivery systems – such as intracameral bimatoprost implants or drug-eluting stents –that aim to address adherence challenges by providing long-term IOP control without daily drops.

Q. What do you think is working well – and what still needs improvement – in co-management or collaborative care between optometrists and ophthalmologists?

Co-management between optometrists and ophthalmologists has strengthened considerably in recent years, driven by clearer referral pathways, enhanced diagnostic technologies, and a growing culture of shared responsibility. What works particularly well is the improved communication surrounding glaucoma, cataract, and ocular surface disease. Many optometrists now operate with advanced imaging – OCT, widefield photography, tonometry and perimetry – allowing high-quality pre-referral assessment and more meaningful triage. This reduces unnecessary specialist visits and enables ophthalmologists to focus on patients with higher clinical needs. Shared-care glaucoma models, especially for stable or low-risk patients, have proved effective and safe when supported by agreed criteria for escalation.

Despite this progress, several areas still require improvement. Communication remains variable, particularly around the quality and completeness of referral information or postoperative updates. Standardised templates, clearer documentation of risk factors, and consistent use of imaging would greatly enhance continuity of care.

Another challenge is variability in clinical thresholds for referral or discharge, which can lead to over-referral, delayed escalation, or duplicated testing. Establishing locally agreed protocols and regular joint education sessions can help align expectations. Access to shared electronic health records would also streamline collaboration, but remains limited by system compatibility and privacy constraints. Finally, role clarity is still evolving: ensuring practitioners understand each other’s scope, strengths, and limitations is essential to maintaining trust and patient safety.

Q. How are new technologies shaping glaucoma outcomes?

New technologies are reshaping the landscape of glaucoma by enabling earlier diagnosis, more accurate monitoring, and safer, more individualised treatment. Advances in diagnostic imaging – particularly spectraldomain and swept-source OCT – allow clinicians to visualise microstructural changes in the retina and optic nerve far earlier than was previously possible.

As mentioned earlier, AI is emerging as a powerful complement to these technologies. Deep-learning algorithms can analyse optic nerve photographs, OCT scans, and retinal images with high accuracy, flagging early disease and stratifying risk in ways that enhance triage and support shared-care models. AI also holds promise for predicting progression, enabling more personalised surveillance intervals and earlier intervention for high-risk patients.

On the management side, minimally invasive glaucoma surgery (MIGS) has transformed early and intermediate treatment of glaucoma by providing safer surgical options with rapid recovery and lower complication rates. These procedures offer targeted pressure reduction and can be integrated with cataract surgery, improving long-term outcomes with far less disruption to patients’ lives. Sustained-release drug-delivery systems are also addressing adherence challenges by providing continuous therapy without daily drops.

Genetic testing platforms, such as Seonix SightScore, enhance personalised glaucoma care by identifying patients with an elevated inherited risk of developing the disease and by highlighting the specific genetic pathways that may be driving their presentation. By integrating genetic variants associated with open-angle glaucoma, clinicians can better predict progression, enabling earlier intervention in patients likely to deteriorate. Test results also guide more individualised treatment intensity – supporting timely initiation of pressure-lowering medications, laser, or closer monitoring schedules. Additionally, genetic insights help differentiate glaucoma from mimicking conditions, improve patient understanding of their disease, and promote adherence by linking management decisions to their unique biological risk profile.

Q. What guidance would you offer optometrists and ophthalmologists to strengthen glaucoma detection, improve referral quality, and optimise patient follow-up?

Improving detection, referral quality, and patient follow-up relies on strengthening both clinical processes and communication between optometrists and ophthalmologists. For optometrists, the most impactful step is to adopt a structured, risk-based approach to case finding. Using high-quality imaging – particularly OCT and perimetry – together with IOP, pachymetry, and family history, improves diagnostic confidence and reduces missed early disease. When uncertainty exists, comparing serial scans and fields rather than relying on a single visit often clarifies progression. Optometrists can also enhance referral quality by providing concise clinical summaries that include symptoms, risk factors, imaging, visual fields, and a clear statement of clinical concern or provisional diagnosis.

For ophthalmologists, timely, practical feedback is essential. Short, structured correspondence that outlines diagnosis, risk level, expected monitoring interval, and clear ‘triggers for re-referral’, helps guide optometrists and reduces unnecessary escalation. Providing examples of typical OCT or optic nerve appearances for specific disease stages can also help calibrate expectations.

Shared protocols are another key enabler. When both professions agree on referral thresholds, imaging requirements, and follow-up intervals, patient flow becomes smoother, safer, and more predictable. Regular joint CPD sessions – case reviews, imaging rounds, or updates on evolving standards – strengthen clinical alignment and build mutual trust.

Finally, improving patient follow-up depends on clear communication with patients: simple explanations of diagnosis, risk, and the importance of monitoring, along with written instructions, significantly improve adherence. Where possible, using consistent terminology across practitioners prevents confusion.

CASE REPORT

Brenton Martin* is an 88-year-old male with myopia and prior cataract surgery who has long-standing primary open-angle glaucoma (POAG) under regular ophthalmic review at the same practice for the past seven years. His treatment regimen consisted of Xalatan nocte and Azarga twice daily to both eyes. Uncorrected visual acuities remained excellent at 6/6 in the right eye and 6/5 in the left. IOPs were consistently well controlled, ranging between 10–13 mmHg at each visit. Serial OCT imaging of the retinal nerve fibre layer and macular ganglion cell complex, together with reliable 24-2 visual fields, (Visual Field Index right 97%, left 99%) showed no structural or functional progression over the entire review period.

Over time, however, attending the urban ophthalmology clinic became increasingly burdensome for Mr Martin due to mobility limitations and reliance on family for transport. To address this problem, his ophthalmologist and optometrist discussed alternative follow-up arrangements that would involve reviews with his optometrist in a more accessible and convenient location. Given the long-term stability of his glaucoma, excellent pressure control, absence of progression, and low risk of significant vision loss in Mr Martin’s lifetime, it was agreed that his long-term monitoring could be safely transitioned to his community optometrist.

A structured shared-care plan was established. The optometrist would review the patient every six to 12 months with IOP measurement, OCT, and visual fields. Clear guidelines were provided for rapid re-referral, including any confirmed structural thinning on OCT, reproducible field defects, sustained IOP above 18 mmHg, new disc haemorrhage, or subjective visual decline. This collaborative approach allowed the patient to continue safe, evidence-based monitoring while greatly reducing the burden of travel and specialist visits.

CONCLUSION

Modern glaucoma management now extends well beyond the walls of any single clinic. It is a shared responsibility that depends on timely information exchange, consistent standards, and a willingness to embrace innovation. By continuing to refine collaborative care pathways and leveraging the full breadth of diagnostic and therapeutic tools available, clinicians across both professions can deliver a more streamlined, equitable, and future-focused model of glaucoma care – one that ensures patients are supported at every stage of their lifelong journey with this chronic disease.

*Patient name changed for anonymity.

Dr Margaret Lam BOptom UNSW Post Grad OcTherapy practises optometry at 1001 Optometry in Bondi Junction in Sydney and teaches at the School of Optometry at the University of New South Wales (UNSW) as an Adjunct Senior Lecturer. She is a past National President of Optometry Australia.

Dr Colin Clement BSc (Hons) MBBS PhD FRANZCO is a Sydney-based ophthalmologist specialising in glaucoma and cataract management and serving as Director of Eye Associates. A leading educator and advocate, he is the course co-ordinator for the MIGS Academy and a key opinion leader in minimally invasive and non-penetrating glaucoma surgery. Dr Clement plays an active regional leadership role as Executive Committee member and Treasurer of the Asia Pacific Glaucoma Society. He has published more than 60 peer-reviewed papers and is frequently invited to speak at national and international meetings.