Can general ophthalmologists take on some of the workload of glaucoma specialists?
Key takeaways:
- One speaker argued that general ophthalmologists could improve early diagnosis of glaucoma.
- Another said glaucoma is a complex disease that necessitates specialist-level knowledge.
SEVILLE, Spain — While glaucoma prevalence is growing, glaucoma specialists are in short supply, and accessibility to specialized centers is limited. Can this gap be filled by general ophthalmologists?
This issue was debated at the Congress on Controversies in Ophthalmology.
For
Joel Suárez, MD, discussed the root of the problem in Spain specifically, which he said is uneven distribution of hospitals in the country. Around half of the hospitals are located in three cities, Madrid, Barcelona and Seville, and rural areas are usually far from secondary and tertiary care facilities.
Published papers on the geographic distribution of ophthalmic subspecialties show that this situation is not much different in the United States.
“We can see how there is a reduction of glaucoma specialists and other subspecialties in the rural areas year after year,” Suárez said.
Problems with access to care have a large impact because if patients are undiagnosed and not properly managed, glaucoma can lead to blindness.
“As a glaucoma surgeon, I have to tell you that our main challenge and principal target is not the operating room but the early diagnosis,” he said. “At least 50% of glaucoma cases remain undiagnosed in Europe, and this rate is far higher in other areas like Asia and Africa.”
This is why general ophthalmologists are an indispensable resource, he said. They have a comprehensive view of eye pathologies, are more accessible and are more than capable of detecting the early signs of glaucoma.
“I think we should devote our efforts to providing education and training for general ophthalmologists in glaucoma,” Suárez said.
He noted that there is increasing interest in AI applied to glaucoma diagnosis, prediction and identification of progression.
“We should take advantage of what this new technology provides us,” he said.
Against
Given the complexity of glaucoma, progression variability and treatment intricacies, management by specialists is bound to lead to better outcomes, fewer complications and enhanced patient satisfaction, according to José Belda, MD, PhD.
Glaucoma is not one disease but a group of chronic, progressive optic neuropathies, and each of them requires different approaches to diagnosis and treatment, necessitating specialist-level knowledge, he said.
It also requires the integration of a number of diagnostic tools that can only be found in specialized clinics, including optic nerve assessment, IOP measurement, visual field testing, advanced imaging, central corneal thickness measurement and gonioscopy.
Misdiagnosis can lead to overtreatment or missed progression, according to Belda, and because the prevalence of glaucoma is growing worldwide, mismanagement of diagnosis or intervention would also have a heavy impact on health care and social costs.
When surgery is required, which has become more common with the advent of MIGS, specific training is needed not only for the procedure but for the follow-up, which is essential to ensure the success of surgery. Training is also imperative to monitor progress and minimize the risk for complications.
Glaucoma specialists are able to achieve this because they manage a high volume of glaucoma cases and a high volume of surgeries, which improves their procedural expertise, according to Belda.
General ophthalmologists are overloaded with work, have long waiting lists and are under a lot of stress from an increasingly high number of patients.
“We cannot stress them more by imposing on them more work and the diagnosis of difficult cases of glaucoma for which they are not properly trained,” Belda said.
However, general ophthalmologists can play a role in a coordinated, team-based, patient-centered care model. This approach can involve optometrists, general ophthalmologists and glaucoma specialists.
Emerging technologies such as AI and new imaging modalities will help to assess more patients, monitor progression and select the cases that need to be treated by glaucoma specialists, Belda said.
An efficient teamwork-based model would meet patients’ expectations and the demand for specialized care, avoiding many potential medicolegal issues.
“Misdiagnosis or delayed treatment under generalist care can lead to legal consequences,” according to Belda’s presentation, so it is necessary to work together.
American Academy of Ophthalmology and European Glaucoma Society guidelines recommend referral to a specialist for moderate or advanced glaucoma, while the initial screening and stable case monitoring can be done by a general ophthalmologist, he said.
References:
- European Glaucoma Society. Br J Ophthalmol. 2021;doi:10.1136/bjophthalmol-2021-egsguidelines.
- Gedde SJ, et al. Ophthalmology. 2021;doi:10.1016/j.ophtha.2020.10.022.
- Gibson DM. Prev Med. 2015;doi:10.1016/j.ypmed.2015.01.008.
- Li F, et al. J Clin Invest. 2022;doi:10.1172/JCI157968.
- Tonti E, et al. J Pers Med. 2024;doi:10.3390/jpm14101062.
- Wang KM, et al. JAMA Ophthalmol. 2022;doi:10.1001/jamaophthalmol.2022.1001.
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Suarez J, et al. Debate 1: Should glaucoma be managed by comprehensive ophthalmologists or glaucoma specialists? Presented at: Congress on Controversies in Ophthalmology; April 4-5, 2025; Seville, Spain.
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