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Overview

This Guidelines summary covers diagnosing and managing glaucoma in people aged 18 and over. It includes recommendations on testing and referral (case-finding) for chronic open-angle glaucoma and ocular hypertension, and on effective diagnosis, treatment, and reassessment to stop these conditions progressing.

For a complete set of recommendations, refer to the full guideline.

Case-finding

  • The recommendations on case-finding are for primary eye care professionals before referral for diagnosis of chronic open angle glaucoma (COAG) and related conditions, and are separate from a sight test.
  • Before referral for further investigation and diagnosis of COAG and related conditions, offer all of the following tests:
    • central visual field assessment using standard automated perimetry (full threshold or supra-threshold)
    • optic nerve assessment and fundus examination using stereoscopic slit lamp biomicroscopy (with pupil dilatation if necessary), and optical coherence tomography (OCT) or optic nerve head image if available
    • intraocular pressure (IOP) measurement using Goldmann-type applanation tonometry
    • peripheral anterior chamber configuration and depth assessments using gonioscopy or, if not available or the person prefers, the van Herick test or OCT.
  • Do not base a decision to refer solely on IOP measurement using non-contact tonometry.
  • Do not refer people who have previously been discharged from hospital eye services after assessment for COAG and related conditions unless clinical circumstances have changed and a new referral is needed.
  • Before deciding to refer, consider repeating visual field assessment and IOP measurement on another occasion to confirm a visual field defect or IOP of 24 mmHg or more, unless clinical circumstances indicate urgent or emergency referral is needed.
  • Refer for further investigation and diagnosis of COAG and related conditions, after considering repeat measures as in the recommendation above, if:
    • there is optic nerve head damage on stereoscopic slit lamp biomicroscopy or
    • there is a visual field defect consistent with glaucoma or
    • IOP is 24 mmHg or more using Goldmann-type applanation tonometry.
  • Provide results of all examinations and tests with the referral.
  • Advise people with IOP below 24 mmHg to continue regular visits to their primary eye care professional.

The following recommendations are for people planning and providing eye care services before referral.

  • People planning and providing eye care services should use a service model that includes Goldmann-type applanation tonometry before referral for diagnosis of COAG and related conditions.
  • People planning eye care services should consider commissioning referral filtering services (for example, repeat measures, enhanced case-finding, or referral refinement) for COAG and related conditions.

Diagnosis

  • To diagnose COAG and related conditions, offer all of the following tests:
    • visual field assessment using standard automated perimetry (central thresholding test), repeated if necessary to establish severity at diagnosis
    • optic nerve assessment and fundus examination using stereoscopic slit lamp biomicroscopy, with pupil dilatation
    • IOP measurement using Goldmann applanation tonometry (slit lamp mounted)
    • peripheral anterior chamber configuration and depth assessments using gonioscopy
    • central corneal thickness (CCT) measurement.
  • Adopt professional or Department of Health and Social Care guidance to reduce the risk of transmitting infective agents via contact tonometry or gonioscopy.
  • Use the van Herick peripheral anterior chamber depth assessment if clinical circumstances rule out gonioscopy (for example, when people with physical or learning disabilities are unable to participate in the examination).
  • Obtain an optic nerve head image at diagnosis for baseline documentation (for example, a stereoscopic optic nerve head image or OCT).
  • After referral, consider an early assessment appointment if there is clinical concern based on the information provided.
  • At the time of diagnosis of ocular hypertension (OHT), assess risk of future visual impairment, taking account of risk factors such as:
    • level of IOP
    • CCT
    • family history
    • life expectancy.

Standard practice for all assessments

  • Ensure that all of the following are available at each clinical episode to all healthcare professionals involved in a person’s care:
    • records of all previous tests and images relevant to COAG and OHT assessment
    • records of past medical history that could affect medicine choice
    • current systemic and topical medication
    • glaucoma medication record
    • drug allergies and intolerances.
  • Use alternative methods of assessment if clinical circumstances rule out standard methods (for example, when people with physical or learning disabilities are unable to participate in the examination).
  • Ensure that all machines and measurement instruments are calibrated regularly according to the manufacturers’ instructions.

Treatment

  • 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.

Treatment for people with OHT

  • Do not offer treatment to people with OHT who are not at risk of visual impairment within their lifetime. Advise people to continue regular visits to their primary eye care professional, at clinically appropriate intervals.

Initial treatment for people with OHT

  • Offer 360° selective laser trabeculoplasty (SLT) to people with newly diagnosed OHT with IOP of 24 mmHg or more (excluding cases associated with pigment dispersion syndrome) if they are at risk of visual impairment within their lifetime (see the recommendation on taking account of risk factors in the section on diagnosis). To help inform their decision, tell people: 
    • that having 360° SLT can delay the need for eye drops and can reduce but does not remove the chance they will be needed at all
    • how long it may take for their IOP to improve after the procedure 
    • about 360° SLT-specific side effects and complications and how long they are likely to last
    • that a second 360° SLT procedure may be needed at a later date. 
  • Consider a second 360° SLT for people with OHT if the effect of an initial successful SLT has subsequently reduced over time.
  • Offer a generic prostaglandin analogue (PGA) to people with OHT with IOP of 24 mmHg or more if they are at risk of visual impairment within their lifetime (see the recommendation on taking account of risk factors in the section on diagnosis) and: 
    • they choose not to have 360° SLT or  
    • 360° SLT is not suitable (for example, because they have pigment dispersion syndrome) or  
    • they are waiting for 360° SLT and need an interim treatment or 
    • they have had 360° SLT but need additional treatment to reduce their IOP sufficiently to prevent the risk of visual impairment. 

      Demonstrate correct eye drop installation technique and observe the person using the correct technique when eye drops are first prescribed.

See the recommendations on when to reassess for advice on when the next appointment should take place to assess the impact of any new treatments started. 

Ongoing treatment for people with OHT

  • Offer another pharmacological treatment to people with an IOP of 24 mmHg or more who cannot tolerate their current treatment. The first choice should be an alternative generic PGA, and if this is not tolerated, offer a beta‑blocker. If neither of these options is tolerated, offer a non-generic PGA, carbonic anhydrase inhibitor, sympathomimetic, miotic or a combination of treatments.
  • Offer a medicine from another therapeutic class (beta-blocker, carbonic anhydrase inhibitor or sympathomimetic) to people with an IOP of 24 mmHg or more whose current treatment is not reducing IOP sufficiently to prevent the risk of progression to sight loss. Topical medicines from different therapeutic classes may be needed at the same time to control IOP.
  • Refer people to a consultant ophthalmologist to discuss other options if their IOP cannot be reduced sufficiently with 360° SLT or pharmacological treatment or both to prevent the risk of progression to sight loss.
  • Offer preservative-free eye drops to people who have an allergy to preservatives or people with clinically significant and symptomatic ocular surface disease, but only if they are at high risk of conversion to COAG.

Treatment for people with suspected COAG

  • Do not offer treatment to people with suspected COAG and IOP less than 24 mmHg unless they are at risk of visual impairment within their lifetime. Advise people to continue regular visits to their primary eye care professional, at clinically appropriate intervals.

Stopping treatment for people with OHT or suspected COAG

  • 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 and
    • an acceptable IOP.

      If a person decides to stop treatment after this discussion, offer to assess their IOP in 1 month to 4 months with further reassessment if clinically indicated.

Treatment for people with COAG

In January 2022 the use of mitomycin-C (MMC) in the recommendation below and the third, fourth, and fifth recommendation in the section Ongoing treatment for people with COAG was off label. See NICE’s information on prescribing medicines.

  • Offer people with advanced COAG glaucoma surgery with pharmacological augmentation (MMC) as indicated. Give them information on the risks and benefits of surgery.
  • Offer people who present with advanced COAG and who are listed for glaucoma surgery, interim treatment with a generic PGA.

Initial treatment for people with COAG

  • Offer 360° SLT to people with newly diagnosed COAG (excluding cases associated with pigment dispersion syndrome). For people with advanced COAG see the section on treatment for people with advanced COAG and the last recommendation in the section Ongoing treatment for people with COAG. To help inform their decision, tell people: 
    • that having 360° SLT can delay the need for eye drops and can reduce but does not remove the chance they will be needed at all 
    • how long it may take for their IOP to improve after the procedure 
    • about 360° SLT-specific side effects and complications and how long they are likely to last 
    • that a second 360° SLT procedure may be needed at a later date.
  • Consider a second 360° SLT for people with COAG if the effect of an initial successful SLT has subsequently reduced over time. 
  • Offer a generic PGA to people with COAG if: 
    • they choose not to have 360° SLT or 
    • 360° SLT is not suitable (for example because they have pigment dispersion syndrome) or 
    • they are waiting for an 360° SLT and need an interim treatment or  
    • they have previously had 360° SLT but need additional treatment to reduce their IOP sufficiently to prevent the risk of visual impairment. 

      Demonstrate correct eye drop installation technique and observe the patient using the technique when eye drops are first prescribed. 

See recommendations on when to reassess for advice on when the next appointment should take place to assess the impact of any new treatments started. 

Ongoing treatment for people with COAG

  • Encourage people to continue with the same pharmacological treatment unless:
    • their IOP cannot be reduced sufficiently to prevent the risk of progression to sight loss
    • there is progression of optic nerve head damage
    • there is progression of visual field defect
    • they cannot tolerate the medicine.
  • Ask about adherence to treatment and check the eye drop instillation technique in people with COAG whose IOP has not been reduced sufficiently to prevent the risk of progression to sight loss, despite pharmacological treatment with a generic PGA. 
  • Offer 1 of the following to people with satisfactory adherence to treatment and eye drop instillation technique whose IOP has not been reduced sufficiently to prevent the risk of progression to sight loss:
    • a medicine from another therapeutic class (a beta-blocker, carbonic anhydrase inhibitor or sympathomimetic); topical medicines from different therapeutic classes may be needed at the same time to control IOP or
    • 360° SLT or
    • glaucoma surgery with pharmacological augmentation (MMC) as indicated.
  • Consider 360° SLT or glaucoma surgery with pharmacological augmentation (MMC) as indicated for people with COAG who are at risk of progressing to sight loss despite treatment with medicines from 2 therapeutic classes. Give them information on the risks and benefits of surgery. 
  • Consider 1 of the following for people with COAG who cannot tolerate a pharmacological treatment:
    • a medicine from another therapeutic class (a beta-blocker, carbonic anhydrase inhibitor or sympathomimetic) or
    • preservative-free eye drops if there is evidence that the person is allergic to the preservative or has clinically significant and symptomatic ocular surface disease.

      After treatment with medicines from 2 therapeutic classes, consider 360° SLT or glaucoma surgery with pharmacological augmentation (MMC) as indicated. 
  • Offer 1 of the following to people with COAG whose IOP has not been reduced sufficiently to prevent the risk of progression to sight loss after glaucoma surgery:
    • pharmacological treatment; topical medicines from different therapeutic classes may be needed at the same time to control IOP or
    • further glaucoma surgery or
    • 360° SLT or
    • cyclodiode laser treatment.
  • Offer 1 of the following to people with COAG (including advanced COAG) who prefer not to have glaucoma surgery or for whom glaucoma surgery is not suitable:
    • pharmacological treatment; topical medicines from different therapeutic classes may be needed at the same time to control IOP or
    • 360° SLT (for example in people with systemic comorbidities) or
    • cyclodiode laser treatment. 

Reassessment

Discharge back to primary care

  • Discharge people back to primary eye care services if:
    • they were referred for OHT but do not need treatment
    • they were referred for suspected COAG but this is no longer suspected.

      Advise people that they should continue with regular visits to their primary eye care professional, at clinically appropriate intervals.
  • Give a discharge summary to people who have been assessed and discharged to primary care. Send a copy to their GP and, with patient consent, copy the relevant information to the primary eye care professional nominated by the patient. Advise people to take their discharge summary with them when attending future sight tests.

Organisation of care

  • Refer people to a consultant ophthalmologist for consideration of a definitive diagnosis and formulation of a management plan if:
    • they have suspected optic nerve damage or repeatable visual field defect, or both, or
    • SLT treatment is suitable (see the first recommendation in the section Initial treatment for people with OHT and the first recommendation in the section Initial treatment for people with COAG for people with newly diagnosed OHT and COAG).
  • Diagnosis of OHT and suspected COAG and formulation of a management plan should be made by a suitably trained healthcare professional with:
    • a specialist qualification and
    • relevant experience.
  • Be aware that holding an independent or non-medical prescribing qualification alone (without a specialist qualification relevant to the case complexity of glaucoma being managed) is insufficient for managing glaucoma and related conditions.

Providing information

  • Ensure that people are offered the opportunity to discuss their diagnosis, referral, prognosis, treatment and discharge so they can take an active part in decision making (see NICE’s guideline on shared decision making). Provide them with relevant information in an accessible format at initial and subsequent visits. This should include telling them:
    • about their specific condition (OHT, suspected COAG and 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 having treatment for COAG will have good quality of life and not go blind
    • that once lost, sight cannot be recovered
    • the different types of treatment options, including mode of action, frequency and severity of side effects, and risks and benefits of treatment
    • that glaucoma can run in families and that family members may wish to be tested for the condition
    • the importance of their role in their own treatment — for example, the ongoing regular application of eye drops to preserve sight.
  • Ensure that people are given practical information and advice on:
    • 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 dilatation would be inadvisable)
    • how to contact the eye clinic liaison officer (ECLO) and what information and assistance they can provide
    • support organisations and support groups
    • compliance aids (such as dispensers) available from their GP or community pharmacist
    • Letter of Vision Impairment (LVI), Referral of Vision Impairment (RVI) and Certificate of Vision Impairment (CVI), registration
    • Driver and Vehicle Licensing Agency (DVLA) regulations.

 

© NICE 2022. Glaucoma: diagnosis and management. Available from: www.nice.org.uk/guidance/NG81. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

Published date: 

Last updated: January 2022.