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Glaucoma

About

What is covered

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

Updates

Updates to this interactive flowchart

11 February 2019 Serious eye disorders (NICE quality standard 180) added.
24 April 2018 Microinvasive subconjunctival insertion of a trans-scleral gelatin stent for primary open-angle glaucoma (NICE interventional procedures guidance 612) added to chronic open-angle glaucoma treatment.
31 October 2017 Updated on publication of glaucoma: diagnosis and management (NICE guideline NG81).
12 September 2017 Ab externo canaloplasty for primary open-angle glaucoma (NICE interventional procedures guidance 591) added.
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.

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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services 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 guideline should be interpreted in a way that would be inconsistent with complying 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.

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 people aged 18 and over with COAG or OHT.

Updates

Updates to this interactive flowchart

11 February 2019 Serious eye disorders (NICE quality standard 180) added.
24 April 2018 Microinvasive subconjunctival insertion of a trans-scleral gelatin stent for primary open-angle glaucoma (NICE interventional procedures guidance 612) added to chronic open-angle glaucoma treatment.
31 October 2017 Updated on publication of glaucoma: diagnosis and management (NICE guideline NG81).
12 September 2017 Ab externo canaloplasty for primary open-angle glaucoma (NICE interventional procedures guidance 591) added.
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.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Glaucoma: diagnosis and management (2009 updated 2017) NICE guideline NG81
Ab externo canaloplasty for primary open-angle glaucoma (2017) NICE interventional procedures guidance 591
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
Serious eye disorders (2019) NICE quality standard 180
ORA G3 to measure corneal hysteresis (2018) NICE medtech innovation briefing 150
Icare rebound tonometer to measure intraocular pressure (2016) NICE medtech innovation briefing 57

Quality standards

Quality statements

Referral for cataract surgery

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

Quality statement

Adults with cataracts are not refused surgery based on visual acuity alone.

Rationale

The decision to undertake cataract surgery should be based on discussions with the person about the effect of cataract on their quality of life, the risks and benefits of surgery and what may happen if they choose not to have surgery. Measurement of visual acuity often fails to detect vision problems that may benefit from cataract surgery (for example, glare and loss of colour vision). The decision should include consideration of a patient’s quality of life and symptoms such as difficulty with reading, night driving, work or home activities, glare and loss of contrast, despite appropriate optical correction. Restricting access to surgery based on visual acuity alone has an impact on quality of life for some people with cataracts. The decision to undertake cataract surgery should be made on the same basis for first and second eyes.

Quality measures

Structure
Evidence of local agreements to include vision difficulties affecting quality of life in the criteria for referral and access to cataract surgery. The same criteria should be used for first- and second-eye cataract surgery.
Data source: Local data collection, for example, service specifications and local commissioning agreements for cataract surgery.
Process
a) Proportion of presentations of cataract where the person has a discussion about how their vision affects their quality of life.
Numerator – the number in the denominator where the person has a discussion about how their vision affects their quality of life.
Denominator – the number of presentations of cataract.
Data source: Local data collection, for example, patient records.
b) Proportion of presentations of cataract that are refused referral for surgery based on visual acuity alone.
Numerator – the number in the denominator that are refused referral for surgery based on visual acuity alone.
Denominator – the number of presentations of cataract.
Data source: Local data collection, for example, patient records or referral records.
c) Proportion of referrals for cataract surgery that are not accepted based on visual acuity alone.
Numerator – the number in the denominator that are not accepted based on visual acuity alone.
Denominator – the number of referrals for cataract surgery.
Data source: Local data collection, for example, patient records or referral records.
Outcome
Health-related quality of life for adults with cataracts.
Data source: Local data collection, for example, results from a questionnaire or patient-reported outcome measure on self-reported improvement after surgery, such as the Cat-PROM5 questionnaire (National Cataract Surgery Audit – Cat-PROM5 currently being piloted).

What the quality statement means for different audiences

Service providers (such as community optometry practices, referral management centres and NHS hospital trusts) ensure that referral pathways for cataract surgery are based on criteria that include vision difficulties affecting quality of life, and not just visual acuity alone. The decision to undertake cataract surgery should be made on the same basis for first and second eyes.
Healthcare professionals (such as ophthalmologists, optometrists, orthoptists and advanced nurse practitioners) base decisions about cataract surgery on a discussion with the person of the impact of the cataract(s) on their quality of life and the risks and benefits of having, and not having, surgery. Visual acuity should not be used as the sole basis for deciding to refer for or perform surgery. The decision to undertake cataract surgery should be made on the same basis for first and second eyes.
Commissioners (clinical commissioning groups and NHS England) commission services that provide access for adults to cataract surgery based on criteria other than visual acuity alone. The other criteria include vision difficulties affecting quality of life. They monitor services to ensure that this is happening. The decision to undertake cataract surgery should be made on the same basis for first and second eyes.
Adults with cataracts are involved in discussion of how cataracts affect their everyday life, how they affect their vision, the risks and benefits of surgery, and what would happen if they chose not to have surgery. Referral for cataract surgery is based on this discussion, and not only on the clarity and sharpness (particularly fine details) with which they can see objects. The decision to perform cataract surgery on the second eye should be made on the same basis.

Source guidance

Cataracts in adults: management (2017) NICE guideline 77, recommendations 1.2.1 and 1.2.2

Definitions of terms used in this quality statement

Based on visual acuity alone
The decision to refer an adult with cataracts for surgery should be based on a discussion with the person of the issues listed below, not on visual acuity alone:
  • how the cataract affects the person's vision and quality of life
  • whether 1 or both eyes are affected
  • what cataract surgery involves, including possible risks and benefits
  • how the person's quality of life may be affected if they choose not to have cataract surgery
  • whether the person wants to have cataract surgery.
[NICE’s guideline on cataracts in adults, recommendation 1.2.1]

Certificate of vision impairment

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

Quality statement

Adults with serious eye disorders are given a certificate of vision impairment (CVI) as soon as they are eligible.

Rationale

A CVI allows easier access to services and support for adults with serious eye disorders. Making a person aware of the benefits associated with a CVI, and giving them the choice of having a CVI as soon as they are eligible, rather than waiting for treatment to finish, allows earlier access to services and support. This can help people retain or regain their independence and improve their wellbeing and quality of life.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with serious eye disorders are given information about the CVI and those meeting the eligibility criteria are given a certificate.
Data source: Local data collection, for example, a service protocol.
Process
Proportion of adults with serious eye disorders that meet the eligibility criteria for a CVI who are given a CVI.
Numerator – the number in the denominator who are given a CVI.
Denominator – the number of adults with serious eye disorders that meet the eligibility criteria for a CVI.
Data source: Local data collection, for example, patient records.
Outcome
Health-related quality of life for adults with serious eye disorders.
Data source: Local data collection, for example, a questionnaire.

What the quality statement means for different audiences

Service providers (NHS hospital trusts and community optometry practices) have systems in place to ensure that adults with serious eye disorders are given information about the support and services associated with certification. They ensure that adults can engage in the process as soon as they meet the eligibility criteria, including while they are having treatment. Services make sure people know about the benefits of certification, and know that they have a choice to have a CVI or not.
Healthcare professionals (optometrists, and ophthalmologists, orthoptists and nurses working in secondary care) make sure that people with serious eye disorders know about the benefits of certification and that they can have a CVI if they choose as soon as they are eligible. This includes while they are having treatment. Professionals give information about the support and services associated with certification. Ophthalmologists sign the certificate to formally certify adults with serious eye disorders as visually impaired.
Commissioners (clinical commissioning groups) ensure that providers have the capacity and resources to give information about the support and services associated with certification to adults with serious eye disorders as soon as they meet the eligibility criteria.
Adults with serious eye disorders are given a certificate of vision impairment as soon as they are eligible. This may be while they are still having treatment. They are also told about support and services, which can help them improve or regain their independence and wellbeing.

Source guidance

Definitions of terms used in this quality statement

Certificate of vision impairment
See the Department of Health and Social Care’s Certificate of vision impairment: explanatory notes for consultant ophthalmologists and hospital eye clinic staff in England, executive summary, sections 4, 9, 21, 29 to 34 inclusive.

Equality and diversity considerations

Healthcare professionals should adapt their communication to the needs of adults with sight difficulties so that they have the opportunity to be involved in decisions relating to certification of vision impairment. This includes being made aware of the benefits associated with having a CVI.
Physical or learning disabilities, hearing problems and difficulties with reading or speaking English, which may affect the patient's involvement in the consultation, should also be considered.
For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services 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 guideline should be interpreted in a way that would be inconsistent with complying 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.

Supporting information

At each assessment, re-evaluate risk of conversion to COAG and risk of sight loss to set time to next assessment.
Take into account any cognitive and physical impairments when making decisions about management and treatment.
Check that there are no relevant comorbidities or potential drug interactions before offering pharmacological treatment.

Referral filtering services

A general term for any type of accuracy checking before referral to hospital eye services. Referral filtering may take the form of 'repeat measures', 'enhanced case-finding', 'referral refinement', 'hospital-based triage' or 'administrative paper-based triage'.
  • Repeat measures
    • The repeated measurement of parameters related to the diagnosis of glaucoma. A simple repeat measures scheme may involve repeat measurement of IOP only. Other repeat measures schemes may also include repeated measurement of visual fields and other relevant ocular parameters when clinically necessary.
  • Enhanced case-finding
    • Enhanced community case-finding services use slit lamp mounted Goldmann-type applanation tonometry, dilated slit lamp indirect biomicroscopy and other tests deemed necessary by the healthcare professional.
  • Referral refinement
    • A 2-tier assessment in which initial evidence of abnormality found during case-finding or screening is validated by an enhanced assessment, which adds value beyond that achieved through a simple 'repeat measures' scheme (for example, repeat measurement of IOP only). A referral refinement service performs tests to diagnose OHT and suspected COAG and interprets the results in the light of clinical findings. Specialist practitioners who deliver this service independently have the qualifications and experience set out in the recommendations on staff training and competencies. Practitioners providing a referral refinement service should be qualified to make a diagnosis of OHT and suspected glaucoma, and to carry out gonioscopy to exclude angle-closure glaucoma.
  • Hospital-based triage
    • A hospital-based risk assessment shortly after referral. Initial tests are performed to determine what happens next. For example, people at a low risk following initial testing by a nurse or technician may be discharged whereas those at higher risk may be directed to a more senior member of the assessment and diagnostic team, such as a consultant ophthalmologist.
Referral refinement is a 2-tier assessment in which initial evidence of abnormality found during case-finding or screening is validated by an enhanced assessment, which adds value beyond that achieved through a simple 'repeat measures' scheme (for example, repeat measurement of IOP only). A referral refinement service performs tests to diagnose OHT and suspected COAG and interprets the results in the light of clinical findings. Specialist practitioners who deliver this service independently have the qualifications and experience set out in the recommendations on staff training and competencies. Practitioners providing a referral refinement service should be qualified to make a diagnosis of OHT and suspected glaucoma, and to carry out gonioscopy to exclude angle-closure glaucoma.
Discuss the benefits and risks of stopping treatment with people with OHT or suspected COAG who have both:
  • a low risk of ever developing visual impairment within their lifetime
  • an acceptable IOP.
If a person decides to stop treatment after this discussion, offer to assess their IOP in 1 to 4 months with further reassessment if clinically indicated.
When clinically indicated, repeat visual field testing using standard automated perimetry (central thresholding test) for people with COAG and those suspected of having visual field defects who are being investigated for possible COAG (see table below for recommended reassessment intervals).
When clinically indicated, repeat visual field testing using either a central thresholding test or a supra-threshold test for people with OHT and those suspected of having COAG whose visual fields have previously been documented by standard threshold automated perimetry (central thresholding test) as being normal (see table below for recommended reassessment intervals).

Glossary

5-fluorouracil
eye clinic liaison officer
central corneal thickness
chronic open-angle glaucoma
certificate of vision impairment
Driver and Vehicle Licensing Agency
letter of vision impairment
intraocular pressure
mitomycin C
optical coherence tomography
ocular hypertension
prostaglandin analogue
(primary eye care professionals include optometrists, GPs with a special interest in ophthalmology and community orthoptists)
(the repeated measurement of parameters related to the diagnosis of glaucoma: a simple repeat measures scheme may involve repeat measurement of IOP only; other repeat measures schemes may also include repeated measurement of visual fields and other relevant ocular parameters when clinically necessary)
referral of vision impairment
(sight loss in glaucoma is visual damage that manifests as blind spots in the field of vision: early on these are mostly asymptomatic with many people being unaware of a problem; sight loss may progress to visual impairment and eventually become symptomatic)
(a sight test determines whether or not a person has a sight defect, and if so what is needed to correct, remedy or relieve it: an optometrist performing a sight test has to conduct the examinations specified in the Sight Testing (Examination and Prescription) (No 2) Regulations 1989; these include an internal and external examination of the eyes and any other examinations needed to detect signs of injury, disease or abnormality in the eye or elsewhere)
(visual impairment is a severe reduction in vision, which cannot be corrected with standard glasses or contact lenses and reduces a person's ability to function in a visual environment)

Paths in this pathway

Pathway created: May 2011 Last updated: February 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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