Prospective study of glaucoma referrals across Europe: Are we using resources wisely?

Panayiota Founti, Fotis Topouzis, Gábor Holló, Barbara Cvenkel, Michele Iester, Anna Bettina Haidich, Péter Kóthy, Anneta Kiana, Despoina Kolokotroni, Ananth C. Viswanathan

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Background: To investigate the outcomes of glaucoma referrals across different European countries. Methods: 250 patients newly referred to tertiary referral glaucoma specialist practices in the UK, Hungary, Slovenia, Italy and Greece were prospectively enrolled (50 consecutive patients per centre). Referral accuracy and predictive value of referral criteria for an intervention or further monitoring (positive predictive value) were analysed. Results: Same-day discharges occurred in 43% (95% CI 39% to 75%) (12/28) of optometrist-initiated referrals (UK only), 37% (95% CI 30% to 45%) (59/158) of ophthalmologist-initiated referrals (all centres) and 54% (95% CI 40% to 68%) (26/48) of self-referrals (Hungary, Italy and Greece). The percentages from all referral sources were 46% (95% CI 32% to 60%) in the UK, 56% (95% CI 44% to 70%) in Hungary, 30% (95% CI 17% to 43%) in Slovenia, 22% (95% CI 11% to 34%) in Italy and 60% (95% CI 46% to 74%) in Greece (p<0.001). Overall, the referring criterion was confirmed in 54% (95% CI 45% to 63%) (64/119) for intraocular pressure (IOP) >21 mm Hg, 56% (95% CI 43% to 69%) (33/59) for a suspicious optic disc and 61% (95% CI 45% to 77%) (22/36) for a suspicious visual field, with large between-country differences (p<0.05 for all comparisons). Of all referrals, 32% (95% CI 26% to 37%) were initiated on the basis of IOP >21 mm Hg only. By combining the IOP criterion with any other referring criterion, the positive predictive value increased from 56% (95% CI 45% to 67%) to at least 89% (95% CI 68% to 100%). In the UK, a hypothetical IOP threshold of >26 mm Hg, as a requirement for IOP-only referrals, would reduce IOP-only referrals by 44%, while not missing any definite glaucoma cases. Conclusion: The accuracy of referrals was poor in the UK and the other countries. Requiring a combination of criteria and raising the IOP threshold for IOP-only referrals are needed to cut waste in clinical care.

Original languageEnglish
Pages (from-to)329-337
Number of pages9
JournalBritish Journal of Ophthalmology
Issue number3
Publication statusPublished - Mar 2018



  • Diagnostic Tests/investigation
  • Epidemiology
  • Glaucoma
  • Intraocular Pressure
  • Optic Nerve

ASJC Scopus subject areas

  • Ophthalmology
  • Sensory Systems
  • Cellular and Molecular Neuroscience

Cite this

Founti, P., Topouzis, F., Holló, G., Cvenkel, B., Iester, M., Haidich, A. B., Kóthy, P., Kiana, A., Kolokotroni, D., & Viswanathan, A. C. (2018). Prospective study of glaucoma referrals across Europe: Are we using resources wisely? British Journal of Ophthalmology, 102(3), 329-337.