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Glaucoma

About

What is covered

This interactive flowchart covers diagnosing and managing glaucoma in adults aged 18 and over with COAG or OHT.

Updates

Updates to this interactive flowchart

15 March 2017 Structure revised, summarised recommendation replaced by full recommendations, and trabecular stent bypass microsurgery for open-angle glaucoma (NICE interventional procedures guidance 575) updated in chronic open-angle glaucoma.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on assessing, treating and managing glaucoma in adults in an interactive flowchart

What is covered

This interactive flowchart covers diagnosing and managing glaucoma in adults aged 18 and over with COAG or OHT.

Updates

Updates to this interactive flowchart

15 March 2017 Structure revised, summarised recommendation replaced by full recommendations, and trabecular stent bypass microsurgery for open-angle glaucoma (NICE interventional procedures guidance 575) updated in chronic open-angle glaucoma.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Glaucoma: diagnosis and management (2009) NICE guideline CG85
Trabecular stent bypass microsurgery for open angle glaucoma (2017) NICE interventional procedures guidance 575
Trabeculotomy ab interno for open angle glaucoma (2011) NICE interventional procedures guidance 397
Canaloplasty for primary open-angle glaucoma (2008) NICE interventional procedures guidance 260
Glaucoma in adults (2011) NICE quality standard 7
Icare rebound tonometer to measure intraocular pressure (2016) NICE medtech innovation briefing 57

Quality standards

Quality statements

Referral 1

This quality statement is taken from the glaucoma in adults quality standard. The quality standard defines clinical best practice for glaucoma in adults and should be read in full.

Quality statement

People are referred to a consultant ophthalmologist for further assessment and definitive diagnosis if the optometrist or other healthcare professional suspects COAG. There are local agreements in place for referral refinement.

Quality measure

Structure
Evidence of arrangements for referral refinement that ensure people are referred to a consultant ophthalmologist for further assessment and definitive diagnosis if the optometrist or other healthcare professional suspects chronic open angle glaucoma (COAG).
Process
a) Proportion of people in whom an optometrist or other healthcare professional suspects COAG who undergo further assessment with referral refinement.
Numerator – the number of people in the denominator who undergo further assessment with referral refinement.
Denominator – the number of people in whom an optometrist or other healthcare professional suspects COAG.
b) Proportion of people who undergo referral refinement who are subsequently referred on to a consultant ophthalmologist for definitive diagnosis because COAG is suspected.
Numerator – the number of people in the denominator who are referred to a consultant ophthalmologist for definitive diagnosis.
Denominator – the number of people undergoing referral refinement because COAG is suspected.

Description of what the quality statement means for each audience

Service providers ensure arrangements are in place for referral refinement to ensure that people are referred to a consultant ophthalmologist for further assessment and definitive diagnosis if the optometrist or other healthcare professional suspects COAG.
Healthcare professionals ensure they are aware of agreements for referral refinement and ensure they refer people to a consultant ophthalmologist for further assessment and definitive diagnosis if they suspect COAG.
Commissioners ensure they commission services with agreements for referral refinement to ensure people are referred to a consultant ophthalmologist for further assessment and definitive diagnosis if the optometrist or other healthcare professional suspects COAG.
People with suspected COAG are referred to a specialist (a consultant ophthalmologist) for further assessment and to confirm the diagnosis. Before referral, further or repeat tests may be carried out to check whether the person should be referred.

Source clinical guideline references

College of Optometrists and Royal College of Ophthalmologists. Guidance on the referral of glaucoma suspects by community optometrists recommendations 5 and 6.

Data source

Structure
Local data collection.
Process
a) and b) Local data collection.

Definitions

Based on NICE clinical guideline 85 recommendations 1.1.1, 1.5.2, 1.5.3 and 1.5.7.
‘Referral refinement' is a term specific to glaucoma management that describes a two-tier assessment in which initial evidence of abnormality during case-finding assessment or screening is validated by a subsequent enhanced assessment which adds value beyond that achieved through a simple ‘repeat measures' scheme. A referral refinement service involves the undertaking of tests sufficient for diagnosis of OHT and suspected COAG and the interpretation of these clinical findings, with specialist practitioners who are delivering this service independently, being qualified and experienced in accordance with NICE guidance.
Features of COAG may include:
  • Optic disc changes consistent with glaucoma in either eye.
  • A visual field defect consistent with glaucoma in either eye.
  • Intraocular pressure (IOP) in either eye exceeding 21 mmHg measured on more than one occasion using Goldmann-style applanation tonometry (identified during screening or case-finding assessment).
  • Other signs often associated with glaucoma.
In the wider context of glaucoma, a narrow anterior chamber drainage angle may be observed on Van Herick testing. This could be consistent with significant risk of acute angle closure within the foreseeable future.

Referral 2

This quality statement is taken from the glaucoma in adults quality standard. The quality standard defines clinical best practice for glaucoma in adults and should be read in full.

Quality statement

People with elevated IOP alone are referred to an appropriately qualified healthcare professional for further assessment on the basis of perceived risk of progression to COAG. There are agreements in place for repeat measures.

Quality measure

Structure
Evidence that there are agreements in place for repeat measures to ensure that people with confirmed elevation of intraocular pressures (IOP) alone (normal optic discs and visual fields) are referred to an appropriately qualified healthcare professional for further assessment on the basis of perceived risk of progression to chronic open angle glaucoma (COAG).
Process
a) Proportion of people with elevation of IOP alone, who are referred for repeat measures to an appropriately qualified healthcare professional.
Numerator – the number of people in the denominator referred for repeat measures to an appropriately qualified healthcare professional.
Denominator – the number of people with suspected elevation of IOP alone.
b) Proportion of people with confirmed elevation of IOP alone, who are referred to an appropriately qualified healthcare professional for further assessment on the basis of perceived risk of progression to COAG.
Numerator – the number of people in the denominator referred to an appropriately qualified healthcare professional on the basis of perceived risk of progression to COAG.
Denominator – the number of people with confirmed elevation of IOP alone.

Description of what the quality statement means for each audience

Service providers ensure arrangements are in place for repeat measures to ensure that people with confirmed elevation of IOP alone are referred to an appropriately qualified healthcare professional for further assessment on the basis of perceived risk of progression to COAG.
Healthcare professionals ensure they are aware of agreements for repeat measures and ensure they refer people with confirmed elevation of IOP alone for further assessment on the basis of perceived risk of progression to COAG.
Commissioners ensure they commission services with agreements for repeat measures which ensure people with confirmed elevation of IOP alone are referred to an appropriately qualified healthcare professional for further assessment on the basis of perceived risk of progression to COAG.
People with raised intraocular pressure (which is the pressure within the eye) have their eye tests repeated, and those with confirmed raised intraocular pressure, but without other eye damage, are referred for further assessment by an appropriate healthcare professional if they are considered likely to develop glaucoma.

Source clinical guideline references

College of Optometrists and Royal College of Ophthalmologists. Guidance on the referral of glaucoma suspects by community optometrists recommendations 5 and 6

Data source

Structure
Local data collection.
Process
a) and b) Local data collection.

Definitions

‘Repeat measures' is a term specific to glaucoma that primarily describes the repeated measurement of eye pressures, but may also include repeated measurement of visual fields and other relevant ocular parameters when clinically necessary.
Elevation of IOP is suspected when a screening device (for example, air puff tonometer) records a reading exceeding 21 mm/Hg.
An appropriately qualified healthcare professional is defined as having specific competencies and training in the assessment and diagnosis of suspected COAG and OHT.
Features suggestive of suspected COAG or OHT may include:
  • Optic disc changes consistent with glaucoma in either eye.
  • A visual field defect consistent with glaucoma in either eye.
  • IOP in either eye exceeding 21 mm/Hg measured on more than one occasion using Goldmann style applanation tonometry (identified during screening or case-finding assessment).
  • Other signs often associated with glaucoma.
  • In the wider context of glaucoma, a narrow anterior chamber drainage angle may be observed on Van Herick testing. This could be consistent with significant risk of acute angle closure within the foreseeable future.

Diagnosis

This quality statement is taken from the glaucoma in adults quality standard. The quality standard defines clinical best practice for glaucoma in adults and should be read in full.

Quality statement

People referred for definitive diagnosis in the context of possible COAG or with OHT receive all relevant tests in accordance with NICE guidance.

Quality measure

Structure
Evidence of arrangements to ensure that people referred for definitive diagnosis in the context of possible COAG (chronic open angle glaucoma) or with OHT (ocular hypertension) receive all relevant tests in accordance with NICE guidance.
Process
Proportion of people referred for definitive diagnosis in the context of possible COAG or with OHT who attend and receive all relevant tests in accordance with NICE guidance.
Numerator – the number of people in the denominator receiving all relevant tests in accordance with NICE guidance.
Denominator – the number of people attending an appointment following a referral for definitive diagnosis in the context of possible COAG or with OHT.

Description of what the quality statement means for each audience

Service providers ensure that people referred for definitive diagnosis in the context of possible COAG or with OHT receive all relevant tests in accordance with NICE guidance.
Healthcare professionals ensure they offer people referred for definitive diagnosis in the context of possible COAG or with OHT all relevant tests in accordance with NICE guidance.
Commissioners ensure they commission services that provide all relevant tests in accordance with NICE guidance for people referred for definitive diagnosis in the context of possible COAG or with OHT.
People who may have glaucoma or increased eye pressure (ocular hypertension) who have been referred for diagnosis receive appropriate eye tests to confirm the diagnosis.

Source clinical guideline references

NICE clinical guideline 85 recommendation 1.1.1 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

NICE clinical guideline 85 recommendations 1.1.1 and 1.1.4 state that relevant tests at diagnosis for COAG, suspected COAG and with OHT may include:
  • IOP measurement using Goldmann applanation tonometry (slit lamp mounted)
  • central corneal thickness (CCT) measurement
  • peripheral anterior chamber configuration and depth assessments using gonioscopy
  • visual field measurement using standard automated perimetry (central thresholding test)
  • optic nerve assessment with dilatation using stereoscopic slit lamp biomicroscopy with fundus examination
  • optic nerve head image for baseline documentation.

Equality and diversity considerations

People with physical or learning disabilities may be unable to participate in some of the relevant diagnostic tests and therefore alternative tests should be offered.

Diagnosis and management plan

This quality statement is taken from the glaucoma in adults quality standard. The quality standard defines clinical best practice for glaucoma in adults and should be read in full.

Quality statement

People with COAG, suspected COAG or with OHT are diagnosed and have a management plan formulated by a suitably trained healthcare professional with competencies and experience in accordance with NICE guidance.

Quality measure

Structure
Evidence of arrangements to ensure that people with chronic open angle glaucoma (COAG), suspected COAG or with ocular hypertension (OHT) are diagnosed and have a management plan formulated by a suitably trained healthcare professional with competencies and experience in the relevant condition in accordance with NICE guidance.
Process
a) Proportion of people with COAG, suspected COAG or with OHT who are diagnosed by a suitably trained healthcare professional with competencies and experience in the relevant condition in accordance with NICE guidance.
Numerator – the number of people in the denominator diagnosed by a suitably trained healthcare professional with competencies and experience in the relevant condition in accordance with NICE guidance.
Denominator – the number of people with COAG, suspected COAG or with OHT.
b) Proportion of people with COAG, suspected COAG or with OHT who have a management plan formulated by a healthcare professional with competencies and experience in the relevant condition in accordance with NICE guidance.
Numerator – the number of people in the denominator with a management plan formulated by a healthcare professional with competencies and experience in the relevant condition in accordance with NICE guidance.
Denominator – the number of people with COAG, suspected COAG or with OHT.

Description of what the quality statement means for each audience

Service providers ensure that people with COAG, suspected COAG or with OHT are diagnosed and managed by a suitably trained healthcare professional with competencies and experience in the relevant condition in accordance with NICE guidance.
Healthcare professionals ensure they have the appropriate qualifications, competencies and experience to diagnose and manage people with COAG, suspected COAG or with OHT in accordance with NICE guidance.
Commissioners ensure they commission services that provide diagnosis and management for people with COAG, suspected COAG or with OHT by suitably trained healthcare professionals with competencies and experience in the relevant condition in accordance with NICE guidance.
People with glaucoma, suspected glaucoma or with ocular hypertension have their condition diagnosed and managed by suitably trained and experienced healthcare professionals.

Source clinical guideline references

NICE clinical guideline 85 recommendations 1.5.1, 1.5.2, 1.5.4 (key priorities for implementation), 1.5.3, 1.5.5, 1.5.6.

Data source

Structure
Local data collection.
Process
a) and b) Local data collection.

Definitions

Based on NICE clinical guideline 85 recommendations 1.5.1–1.5.6.
The diagnosis and formulation of a management plan for COAG should be the responsibility of a consultant ophthalmologist.
Healthcare professionals involved in the diagnosis of OHT and suspected COAG should have a specialist qualification or be working under the supervision of a consultant ophthalmologist; relevant experience; and should be able to perform and interpret:
  • medical and ocular history
  • differential diagnosis
  • Goldmann applanation tonometry (slit lamp mounted)
  • standard automated perimetry (central thresholding test)
  • central supra-threshold perimetry
  • stereoscopic slit lamp biomicroscopic examination of anterior segment
  • examination of the posterior segment using slit lamp binocular indirect ophthalmoscopy
  • gonioscopy
  • Van Herick's peripheral anterior chamber depth assessment
  • central corneal thickness (CCT) measurement.
Healthcare professionals involved in monitoring and treatment of people with OHT, suspected COAG and established COAG should have a specialist qualification or be working under the supervision of a consultant ophthalmologist; relevant experience; and should be trained and able to make management decisions on:
  • risk factors for conversion to COAG
  • coexisting pathology
  • risk of sight loss
  • monitoring and clinical status change detection (for example, visual field changes, stereoscopic slit lamp biomicroscopic examination of anterior segment and posterior segment)
  • pharmacology of IOP-lowering medications
  • treatment changes for COAG, COAG suspect status and OHT (with consideration given to relevant contraindications and interactions).
Healthcare professionals involved in monitoring (but not treating) people with an established diagnosis and management plan for OHT or suspected COAG should have knowledge of OHT and COAG; relevant experience and ability to detect a change in clinical status; and should be able to perform and interpret all of the following:
  • Goldmann applanation tonometry (slit lamp mounted)
vstandard automated perimetry (central thresholding test)
  • central supra-threshold perimetry (this visual field strategy may be used to monitor people with OHT or COAG suspect status when they have normal visual field)
  • stereoscopic slit lamp biomicroscopic examination of the anterior segment
  • Van Herick's peripheral anterior chamber depth assessment
  • examination of the posterior segment using slit lamp binocular indirect ophthalmoscopy.
Healthcare professionals who do not have a specialist qualification and who are working under supervision should have direct access to their supervising consultant ophthalmologist or designated delegate.

Monitoring

This quality statement is taken from the glaucoma in adults quality standard. The quality standard defines clinical best practice for glaucoma in adults and should be read in full.

Quality statement

People diagnosed with COAG, suspected COAG or with OHT are monitored at intervals according to their risk of progressive loss of vision in accordance with NICE guidance.

Quality measure

Structure
Evidence of arrangements to ensure that people diagnosed with chronic open angle glaucoma (COAG), suspected COAG or with ocular hypertension (OHT) are monitored at intervals according to their risk of progressive loss of vision in accordance with NICE guidance.
Process
Proportion of people with COAG, suspected COAG or with OHT who are monitored at intervals according to their risk of progressive loss of vision in accordance with NICE guidance.
Numerator – the number of people in the denominator monitored at intervals according to their risk of progressive loss of vision in accordance with NICE guidance.
Denominator – the number of people diagnosed with COAG, suspected COAG or with OHT.

Description of what the quality statement means for each audience

Service providers ensure that people diagnosed with COAG, suspected COAG or with OHT are monitored at intervals according to their risk of progressive loss of vision in accordance with NICE guidance.
Healthcare professionals ensure they monitor people diagnosed with COAG, suspected COAG or with OHT at intervals according to their risk of progressive loss of vision in accordance with NICE guidance.
Commissioners ensure they commission services that monitor people diagnosed with COAG, suspected COAG or with OHT in accordance with NICE guidance.
People diagnosed with glaucoma, suspected glaucoma or with ocular hypertension are checked at regular intervals depending on how likely it is that their condition will get worse.

Source clinical guideline references

NICE clinical guideline 85 recommendation 1.2.10, 1.2.14 (key priorities for implementation), 1.2.11, 1.2.12, 1.2.15.

Data source

Structure
Local data collection.
Process
Local data collection. The National Patient Safety Agency Reporting and Learning System records the number of patient safety incidents reported to the National Patient Safety Agency for visual loss attributable to COAG that occur in association with delays in follow-up appointments.

Definitions

People with COAG, suspected COAG or with OHT will be monitored in accordance with NICE guidance if they are monitored at intervals according to their risk of progressive loss of vision or risk of conversion to COAG as set out in NICE clinical guideline 85 recommendation 1.2.10–1.2.15.

Management based on estimated risk of conversion to COAG and progression to visual impairment

This quality statement is taken from the glaucoma in adults quality standard. The quality standard defines clinical best practice for glaucoma in adults and should be read in full.

Quality statement

People with suspected COAG or with OHT are managed based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age, in accordance with NICE guidance.

Quality measure

Structure
Evidence of arrangements to ensure that people with suspected chronic open angle glaucoma (COAG) or with ocular hypertension (OHT) are managed based on estimated risk of conversion to COAG and progression to visual impairment using intraocular pressure (IOP), central corneal thickness (CCT) and age, in accordance with NICE guidance.
Process
a) Proportion of people diagnosed with suspected COAG or with OHT who are assessed for treatment eligibility based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age.
Numerator – the number of people in the denominator assessed for treatment eligibility based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age.
Denominator – the number of people diagnosed with suspected COAG or with OHT.
b) Proportion of people diagnosed with suspected COAG or with OHT who are eligible for treatment based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age, who are managed in accordance with NICE guidance.
Numerator – the number of people in the denominator managed in accordance with NICE guidance.
Denominator – the number of people diagnosed with suspected COAG or with OHT who are eligible for treatment based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age.
c) Proportion of people diagnosed with suspected COAG or with OHT at low risk of progressing to visual impairment who receive no treatment in accordance with NICE guidance.
Numerator – the number of people in the denominator who receive no treatment in accordance with NICE guidance.
Denominator – the number of people diagnosed with suspected COAG or with OHT at low risk of progressing to visual impairment for whom treatment is not recommended by NICE guidance.

Description of what the quality statement means for each audience

Service providers ensure that people with suspected COAG or with OHT are managed based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age, in accordance with NICE guidance.
Healthcare professionals ensure that they manage people with suspected COAG or with OHT who are eligible for treatment based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age, in accordance with NICE guidance.
Commissioners ensure they commission services that manage people with suspected COAG or with OHT based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age, in accordance with NICE guidance.
People with suspected glaucoma or with ocular hypertension may be offered treatment depending on their estimated risk of developing glaucoma and sight loss.

Source clinical guideline references

NICE clinical guideline 85 recommendation 1.3.1 (key priority for implementation) and recommendation1.3.2.

Data source

Structure
Local data collection.
Process
a), b) and c) Local data collection.

Definitions

People with suspected COAG or with OHT may have suspicious optic nerve head appearances but should have normal visual fields (exceptions may arise in the presence of co-pathology).
People with suspected COAG or with OHT will be managed according to NICE guidance if they are treated or not treated according to NICE clinical guideline 85 recommendations 1.3.1 and 1.3.2.

Stopping treatment

This quality statement is taken from the glaucoma in adults quality standard. The quality standard defines clinical best practice for glaucoma in adults and should be read in full.

Quality statement

People with COAG, suspected COAG or with OHT have a regular review of management options with their healthcare professional, taking into account comorbidity and other changed circumstances, including a discussion of the benefits and risks of stopping treatment for those at low risk of progressing to visual impairment.

Quality measure

Structure
Evidence of arrangements to ensure that people with chronic open angle glaucoma (COAG), suspected COAG or with ocular hypertension (OHT) have a regular review of management options with their healthcare professional, taking into account comorbidity and other changed circumstances, including a discussion of the benefits and risks of stopping treatment for those at low risk of progressing to visual impairment.
Process
a) Proportion of people with COAG, suspected COAG or with OHT who have a regular review of management options with their healthcare professional taking into account comorbidity and other changed circumstances.
Numerator – the number of people in the denominator having a regular review of management options with their healthcare professional taking into account comorbidity and other changed circumstances.
Denominator – the number of people with COAG, suspected COAG or with OHT.
b) Proportion of people with COAG, suspected COAG or with OHT at low risk of progressing to visual impairment who have a discussion of the benefits and risks of stopping treatment.
Numerator – the number of people in the denominator participating in a discussion of the benefits and risks of stopping treatment.
Denominator – the number of people with COAG suspected COAG or with OHT at low risk of progressing to visual impairment.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to ensure that people with COAG, suspected COAG or with OHT have a regular review of management options with their healthcare professional acknowledging comorbidity and other changed circumstances, including a discussion of the benefits and risks of stopping treatment for those at low risk of progressing to visual impairment.
Healthcare professionals ensure that people with COAG, suspected COAG or with OHT have a regular review of management options that acknowledges comorbidity and other changed circumstances, including a discussion of the benefits and risks of stopping treatment for those at low risk of progressing to visual impairment.
Commissioners ensure they commission services that ensure that people with COAG, suspected COAG or with OHT have a regular review of management options with their healthcare professional acknowledging comorbidity and other changed circumstances, including a discussion of the benefits and risks of stopping treatment for those at low risk of progressing to visual impairment.
People with glaucoma, suspected glaucoma or with ocular hypertension have a regular review with their healthcare professional to discuss their treatment, which should take into account any other health problems or changes in the person's circumstances. For people at low risk of developing sight loss, the benefits and risks of stopping treatment should also be discussed.

Source clinical guideline references

NICE clinical guideline 85 recommendations 1.2.10 (key priority for implementation), 1.2.11.

Data sources

Structure
Local data collection.
Process
a) and b) Local data collection.

Definitions

Comorbidities and changed circumstances that should be taken into account when reviewing management options for people with COAG, suspected COAG or with OHT include:
  • chronic obstructive pulmonary disease
  • asthma cardiovascular disease
  • renal disease
  • haematological conditions
  • ocular comorbidities
  • pregnancy drug sensitivities.
People with suspected COAG or with OHT recommended to receive medication are monitored in accordance with NICE guidance if they are monitored at regular intervals and according to their risk of conversion to COAG (see table 4 of recommendation 1.2.10 in NICE clinical guideline 85).
People with suspected COAG or with OHT recommended to receive medication are those specified in recommendation 1.3.1 of NICE clinical guideline 85.

Service capacity

This quality statement is taken from the glaucoma in adults quality standard. The quality standard defines clinical best practice for glaucoma in adults and should be read in full.

Quality statement

People diagnosed with COAG, suspected COAG or with OHT have access to timely follow-up appointments and specialist investigations at intervals in accordance with NICE guidance. Sufficient capacity is put in place to provide this service, and systems are developed to identify people needing clinical priority if appointments are cancelled, delayed or missed.

Quality measure

Structure
a) Evidence of arrangements to ensure people diagnosed with chronic open angle glaucoma (COAG), suspected COAG or with ocular hypertension (OHT) have access to timely follow-up appointments and specialist investigations in accordance with NICE guidance.
b) Evidence of arrangements to ensure sufficient capacity is put in place to provide this service and systems are developed to identify people needing clinical priority if appointments are cancelled, delayed or missed.
Process
a) Proportion of people with COAG, suspected COAG or with OHT who have access to timely follow-up appointments and specialist investigations at appropriate intervals in accordance with NICE guidance.
Numerator – the number of available appointments and specialist investigations for people with COAG, suspected COAG or with OHT.
Denominator – the number of requested appointments and specialist investigations for people with COAG, suspected COAG or with OHT.
b) Proportion of people with COAG, suspected COAG or with OHT, whose appointment has been cancelled, delayed or missed who have their clinical priority assessed.
Numerator – the number of people in the denominator with a clinical priority assessment.
Denominator – the number of people with COAG, suspected COAG or with OHT and a cancelled, delayed or missed appointment.
c) Proportion of people with COAG, suspected COAG or with OHT whose cancelled, delayed or missed appointment is rescheduled within an appropriate time interval.
Numerator – the number of people in the denominator with a rescheduled appointment following a cancelled, delayed or missed appointment within an appropriate time interval.
Denominator – the number of people with COAG, suspected COAG or with OHT with a cancelled, delayed or missed appointment.

Description of what the quality statement means for each audience

Service providers ensure they provide sufficient capacity to meet clinical demand and identify those needing clinical priority if appointments are cancelled, delayed or missed and that appointments take place within an appropriate interval time.
Healthcare professionals ensure that incidents of cancellation or delay of appointments beyond appropriate time intervals are reported through clinical governance channels.
Commissioners ensure they commission services with sufficient capacity to meet clinical demand and that ensure those needing clinical priority if appointments are cancelled, delayed or missed are identified and that appointments take place within an appropriate time interval.
People with glaucoma, suspected glaucoma or with ocular hypertension are offered appointments within an appropriate time interval to review their condition or for specialist assessment, including those that have been rescheduled due to appointments being cancelled, delayed or missed.

Source clinical guideline references

National Patient Safety Agency. Rapid Response Report. Preventing delay to follow up for patients with glaucoma (RR004); 2, 4 and 5.
NICE clinical guideline 85 recommendations 1.2.10 and 1.2.14 (key priorities for implementation) and recommendations1.2.12 and 1.2.13.

Data source

Structure
a) and b) Local data collection.
Process
Local data collection a), b) and c). The National Patient Safety Agency Reporting and Learning System records the number of patient safety incidents reported to the National Patient Safety Agency for visual loss attributable to COAG which occur in association with delays in follow-up appointments.

Definitions

Timely follow up appointments are defined as appointments and specialist investigations at intervals in accordance with NICE clinical guideline 85 recommendations 1.2.10 and 1.2.14 (key priorities for implementation) and recommendations1.2.12 and 1.2.13.
The Royal College of Ophthalmologists suggests that cancelled, delayed or missed appointments should be rescheduled within 15% of the intended interval time, for example, a rescheduled 6 month request should take place within less than 7 months.

Documentation

This quality statement is taken from the glaucoma in adults quality standard. The quality standard defines clinical best practice for glaucoma in adults and should be read in full.

Quality statement

Healthcare professionals involved in the care of a person with COAG, suspected COAG or with OHT have appropriate documentation and records available at each clinical encounter in accordance with NICE guidance.

Quality measure

Structure
Evidence of arrangements to ensure that healthcare professionals involved in a person's care have appropriate documentation available at each clinical encounter in accordance with NICE guidance.
Process
Proportion of people with chronic open angle glaucoma (COAG), suspected COAG or with ocular hypertension (OHT) whose documentation and records are available to healthcare professionals at each clinical encounter.
Numerator – the number of people in the denominator whose documentation and records are available to the healthcare professional(s) present.
Denominator – the number of people with COAG, suspected COAG or with OHT attending a clinic appointment.

Description of what the quality statement means for each audience

Service providers ensure that appropriate documentation and records are available to healthcare professionals involved in a person's care in accordance with NICE guidance.
Healthcare professionals ensure they share all appropriate documentation and records with other healthcare professionals involved in the care of people with COAG, suspected COAG or with OHT, and should also ensure that lack of documentation is reported through clinical governance channels.
Commissioners ensure they commission services that make appropriate documentation and records available at each clinical encounter.
People with glaucoma, suspected glaucoma or with ocular hypertension are seen by healthcare professionals who have access to the person's records, which should include information on test results, past medical problems, current and previous medication details, drug allergies and intolerances.

Source clinical guideline references

NICE clinical guideline 85 recommendation 1.1.5 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

NICE clinical guideline 85 recommendation 1.1.5 states that appropriate documentation and records include:
  • records of all previous tests and images relevant to COAG and OHT assessment
  • records of past surgical and medical history which could affect management
  • current systemic and topical medication
  • glaucoma medication record
  • drug allergies and intolerances.

Surgery

This quality statement is taken from the glaucoma in adults quality standard. The quality standard defines clinical best practice for glaucoma in adults and should be read in full.

Quality statement

People with COAG who are progressing to loss of vision despite treatment or who present with advanced visual loss are offered surgery with pharmacological augmentation (for example, MMC or 5FU) as indicated and information on the risks and benefits associated with surgery.

Quality measure

Structure
Evidence of arrangements to ensure that all people with chronic open angle glaucoma (COAG) who are progressing to loss of vision despite treatment or who present with advanced visual loss are offered surgery with pharmacological augmentation (for example, mitomycin C [MMC] or 5-fluorouracil [5FU]; see definitions below) as indicated and information on the risks and benefits associated with surgery.
Process
a) Proportion of people with COAG who are progressing to loss of vision despite treatment or who present with advanced visual loss who are offered surgery with pharmacological augmentation (for example, MMC or 5FU) as indicated.
Numerator – the number of people in the denominator offered surgery with pharmacological augmentation (for example, MMC or 5FU) as indicated.
Denominator – the number of people with COAG progressing to loss of vision despite treatment or who present with advanced visual loss.
b) Proportion of people with COAG offered surgery because they are progressing to loss of vision despite treatment or who present with advanced visual loss, who receive information on the risks and benefits associated with surgery.
Numerator – the number of people in the denominator who receive information on the risks and benefits associated with surgery.
Denominator – the number of people with COAG who are offered surgery because they are progressing to loss of vision despite treatment or who present with advanced visual loss.

Description of what the quality statement means for each audience

Service providers ensure that people with COAG progressing to loss of vision despite treatment or who present with advanced visual loss are offered surgery with pharmacological augmentation (for example, MMC or 5FU) as indicated and are offered information on the risks and benefits associated with surgery.
Healthcare professionals ensure they offer surgery with pharmacological augmentation (for example, MMC or 5FU) as indicated to people with COAG progressing to loss of vision despite treatment or who present with advanced visual loss, and offer information on the risks and benefits associated with surgery.
Commissioners ensure they commission services that offer surgery with pharmacological augmentation (for example, MMC or 5FU) as indicated to people with COAG progressing to loss of vision despite treatment or who present with advanced visual loss, and that information on the risks and benefits associated with surgery is offered to them.
People with glaucoma who are losing their sight despite treatment and those diagnosed with glaucoma at an advanced stage are offered surgery and given information on the risks and benefits of surgery.

Source clinical guideline references

NICE clinical guideline 85 recommendation 1.4.7 (key priority for implementation).

Data source

Structure
Local data collection.
Process
a) Local data collection. Hospital Episode Statistics (HES)collect data on the number of people who have surgery, but do not collect data on those offered surgery.
b) Local data collection.

Definitions

At the time of publication of NICE clinical guideline 85 (April 2009) MMC and 5FU did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. Both drugs should be handled with caution and in accordance with guidance issued by the Health and Safety Executive.

Information

This quality statement is taken from the glaucoma in adults quality standard. The quality standard defines clinical best practice for glaucoma in adults and should be read in full.

Quality statement

People with COAG, suspected COAG or with OHT are given the opportunity to discuss their diagnosis, prognosis and management, and are provided with relevant and accessible information and advice at initial and subsequent visits in accordance with NICE guidance.

Quality measure

Structure
Evidence of arrangements to ensure that people with chronic open angle glaucoma (COAG), suspected COAG or with ocular hypertension (OHT) are given the opportunity to discuss their diagnosis, prognosis and management, and are provided with relevant and accessible information and advice at initial and subsequent visits in accordance with NICE guidance.
Process
Proportion of people with COAG, suspected COAG or with OHT who are given the opportunity to discuss their diagnosis, prognosis and management and who are provided with relevant and accessible information and advice at initial and subsequent visits in accordance with NICE guidance.
Numerator – the number of people in the denominator given the opportunity to discuss their diagnosis, prognosis and management and provided with relevant and accessible information and advice at initial and subsequent visits in accordance with NICE guidance.
Denominator – the number of people with COAG, suspected COAG or with OHT.

Description of what the quality statement means for each audience

Service providers ensure that people with COAG, suspected COAG or with OHT are able to discuss their diagnosis, prognosis and management, and are provided with relevant and accessible information and advice at initial and subsequent visits in accordance with NICE guidance.
Healthcare professionals discuss diagnosis, prognosis and management with people with COAG, suspected COAG or with OHT and provide them with relevant and accessible information and advice at initial and subsequent visits in accordance with NICE guidance.
Commissioners ensure they commission services that offer people with COAG, suspected COAG or with OHT the opportunity to discuss their diagnosis, prognosis and management at initial and subsequent visits, and that provide relevant and accessible information and advice in accordance with NICE guidance.
People with glaucoma, suspected glaucoma or with ocular hypertension have the opportunity to discuss their diagnosis, prognosis (what their sight may be like in the future) and treatment, and are provided with relevant information in a suitable format and advice at each appointment.

Source clinical guideline references

NICE clinical guideline 85 recommendation 1.6.1 (key priority for implementation).

Data source

Process
Local data collection.
Structure
Local data collection.

Definitions

Relevant information and advice should address management options and assessment of eye drop instillation technique.
NICE clinical guideline 85 recommendation 1.6.1 states that relevant information may include the following:
  • their specific condition (OHT, suspected COAG or COAG), its life-long implications and their prognosis for retention of sight
  • that COAG in the early stages and OHT and suspected COAG are symptomless
  • that most people treated for COAG will not go blind
  • that once lost, sight cannot be recovered
  • that glaucoma can run in families and that family members may wish to be tested for the disease
  • the importance of the person's role in their own treatment – for example, the ongoing regular application of eye drops to preserve sight
  • the different types of treatment options, including mode of action, frequency and severity of side effects, and risks and benefits of treatment, so that people are able to be active in the decision-making process
  • how to apply eye drops, including technique (punctal occlusion and devices and hygiene (storage)
  • the need for regular monitoring as specified by the healthcare professional
  • methods of investigation during assessment
  • how long each appointment is likely to take and whether the person will need any help to attend (for example, driving soon after pupil dilation would be inadvisable)
  • support groups
  • compliance aids (such as dispensers) available from their GP or community pharmacist
  • Letter of Vision Impairment (LVI), Referral of Vision Impaired Patient (RVI) and Certificate of Vision Impairment (CVI) registration
  • Driver and Vehicle Licensing Agency (DVLA) regulations
  • information on how to access help with eye drops and devices if required.

Equality and diversity considerations

All information should be provided in an accessible format tailored to the needs of the individual. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People with COAG, suspected COAG or with OHT should have access to an interpreter or advocate if needed.

Discharge

This quality statement is taken from the glaucoma in adults quality standard. The quality standard defines clinical best practice for glaucoma in adults and should be read in full.

Quality statement

People with suspected COAG or with OHT who are not recommended for treatment and whose condition is considered stable are discharged from formal monitoring with a patient-held management plan.

Quality measure

Structure
Evidence of arrangements to ensure that all people with suspected chronic open angle glaucoma (COAG) or with ocular hypertension (OHT) who are not recommended for treatment and whose condition is considered stable are discharged from formal monitoring with a patient-held management plan.
Process
Proportion of people with suspected COAG or with OHT who are not recommended for treatment and whose condition is considered stable who are discharged from formal monitoring with a patient-held management plan.
Numerator – the number of people in the denominator discharged from formal monitoring with a patient-held management plan.
Denominator – the number of people with suspected COAG or with OHT who are not recommended for treatment and whose condition is considered stable.

Description of what the quality statement means for each audience

Service providers ensure that people with suspected COAG or with OHT who are not recommended for treatment and whose condition is considered stable are discharged from formal monitoring with a patient-held management plan.
Healthcare professionals ensure they discharge people with suspected COAG or with OHT who are not recommended for treatment and whose condition is considered stable from formal monitoring with a patient-held management plan.
Commissioners ensure they commission services that discharge people with COAG or with OHT who are not recommended for treatment and whose condition is stable from formal monitoring with a patient-held management plan.
People with suspected glaucoma or with ocular hypertension who do not need treatment and whose condition is considered stable are discharged from regular glaucoma monitoring and are given information to take home about their condition, which includes details of tests, how often they should return and when they should next be reviewed.

Source clinical guideline references

NICE clinical guideline 85 recommendation 1.2.12, 1.2.13.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

NICE clinical guideline 85 recommendation 1.2.12 states that if no change in parameters for intraocular pressure, optic nerve head and visual field is detected in people with OHT or suspected COAG who are not recommended to receive medication after 3–5 years (depending on perceived risk of conversion) or before if confirmed normal, then the person should be discharged from active glaucoma care to community optometric care.
NICE clinical guideline 85 recommendation 1.2.13 states that at discharge people who are not recommended for treatment and whose condition is considered stable are advised to visit their primary care optometrist annually so that any future changes in their condition can be detected.
A patient-held management plan should include details of the following:
  • diagnosis
  • relevant clinical information such as
    • copies of disc imaging
    • copies of visual field
    • central corneal thickness threshold
    • intraocular pressure for return referral
  • return referral criteria
  • review interval.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Monitoring intervals for people with chronic open-angle glaucoma
Clinical assessment
Monitoring intervals (months)
IOP at targetIOP at or below target.
ProgessionProgression = increased optic nerve damage and/or visual field change confirmed by repeated test where clinically appropriate.
OutcomeFor change of treatment plan refer to treatment recommendations.
IOP aloneFor people started on treatment for the first time check IOP 1 to 4 months after start of medication.
IOP, optic nerve head and visual field
Yes
NoNo = not detected or not assessed if IOP check only following treatment change.
No change in treatment plan
Not applicable
6 to 12
Yes
Yes
Review target IOP or change treatment plan
1 to 4
2 to 6
Yes
Uncertain
No change in treatment plan
Not applicable
2 to 6
No
No
Review target IOP or change treatment plan
1 to 4
6 to 12
No
Yes/uncertain
Change treatment plan
1 to 2
2 to 6
Treatment for people with ocular hypertension or suspected chronic open-angle glaucoma
More than 590 micrometres
555 to 590 micrometres
Less than 555 micrometres
Any
Untreated IOP (mmHg)
> 21 to 25
> 25 to 32
> 21 to 25
> 25 to
32
> 21 to
25
> 25 to
32
> 32
Age (years)Treatment should not be routinely offered to people over the age threshold unless there are likely to be benefits from the treatment over an appropriate timescale. Once a person being treated for OHT reaches the age threshold for stopping treatment but has not developed COAG, healthcare professionals should discuss the option of stopping treatment. The use of age thresholds is considered appropriate only where vision is currently normal (OHT with or without suspicion of COAG) and the treatment is purely preventative. Under such circumstances the threat to a person's sighted lifetime is considered negligible. In the event of COAG developing in such a person then treatment is recommended.
Any
Any
Any
Treat until 60
Treat until 65
Treat until 80
Any
Treatment
No treatment
No treatment
No treatment
Beta-blockerIf beta-blockers are contraindicated offer a PGA.
PGA
PGA
PGA

Glossary

5-fluorouracil
defined using the Hodapp classification of visual field loss for the stages of glaucoma (see section 1.8.6 of the full guideline), and summarised approximately in terms of mean defect as -12 dB to greater than -20 dB
central corneal thickness
chronic open-angle glaucoma: glaucoma without evident secondary cause, which follows a chronic time course and occurs in the presence of an open anterior chamber angle (the trabecular meshwork is visible on gonioscopy); the term is used regardless of the level of intraocular pressure and has been extended to include COAG associated with pseudoexfoliation and pigment dispersion
certificate of vision impairment
Driver and Vehicle Licensing Agency
defined using the Hodapp classification of visual field loss for the stages of glaucoma (see section 1.8.6 of the full guideline), and summarised approximately in terms of mean defect as greater than -6 dB
letter of vision impairment
intraocular pressure
mitomycin C
defined using the Hodapp classification of visual field loss for the stages of glaucoma (see section 1.8.6 of the full guideline), and summarised approximately in terms of mean defect as -6 dB to greater than -12 dB
ocular hypertension
prostaglandin analogue
referral of vision impairment

Paths in this pathway

Pathway created: May 2011 Last updated: March 2017

© NICE 2017

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