Glaucoma: Diagnosis and Management Glaucoma: Diagnosis and Management

Glaucoma: diagnosis and management
NICE guideline
Published: 1 November 2017
nice.org.uk/guidance/ng81
© NICE 2018. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-of-

rights).
Glaucoma: diagnosis and management (NG81)
Your responsibility
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.
© NICE 2018. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and- Page 2 of
conditions#notice-of-rights). 41
Contents
Overview ............................................................................................................................................................................. 4
Who is it for? .................................................................................................................................................................................... 4
Recommendations ........................................................................................................................................................... 5
1.1 Case-finding ............................................................................................................................................................................. 5
1.2 Diagnosis.................................................................................................................................................................................... 6
1.3 Standard practice for all assessments ............................................................................................................................ 7
1.4 Reassessment........................................................................................................................................................................... 8
1.5 Treatment .................................................................................................................................................................................. 12
1.6 Organisation of care .............................................................................................................................................................. 15
1.7 Providing information........................................................................................................................................................... 18
Terms used in this guideline ....................................................................................................................................................... 19
Putting this guideline into practice ........................................................................................................................... 22
Context................................................................................................................................................................................. 24
More information........................................................................................................................................................................... 24
Recommendations for research ................................................................................................................................. 25
1 Risk tools to identify risk of developing COAG and risk of sight loss .................................................................... 25
2 Treatment for people with an IOP of 22 or 23 mmHg ................................................................................................. 25
3 An instrument to measure quality of life in people with glaucoma ........................................................................ 26
4 Optical coherence tomography for glaucoma ................................................................................................................ 26
5 Referral filtering.......................................................................................................................................................................... 27
Update information......................................................................................................................................................... 29
Recommendations that have been changed ....................................................................................................................... 29
This guideline replaces CG85.
This guideline is the basis of QS7.
Ov
Overview
erview
This guideline 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.
We have produced a large print version of this guideline which is available to download in tools and
resources.
Who is it for?
Healthcare professionals
Commissioners and providers of eye care services
Adults with chronic open angle glaucoma or ocular hypertension, or who are at risk of
developing glaucoma, their families and carers
Recommendations
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.
1.1 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.
1.1.1 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 patient prefers, the van Herick test or OCT. [2017]
1.1.2 Do not base a decision to refer solely on IOP measurement using non-contact
tonometry. [2017]
1.1.3 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. [2017]
1.1.4 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. [2017]
1.1.5 Refer for further investigation and diagnosis of COAG and related conditions,
after considering repeat measures as in recommendation 1.1.4, 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. [2017]
1.1.6 Provide results of all examinations and tests with the referral. [2017]
1.1.7 Advise people with IOP below 24 mmHg to continue regular visits to their
primary eye care professional. [2017]
These recommendations are for people planning and pro

providing
viding e
eyye care services before referr
referral
al
1.1.8 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. [2017]
1.1.9 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. [2017]
1.2 Diagnosis
1.2.1 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. [2017]
1.2.2 Adopt professional[ ]/Department of Health[ ] guidance to reduce the risk of

1 2
transmitting infective agents via contact tonometry or gonioscopy. [2009]
1.2.3 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). [2009]
1.2.4 Obtain an optic nerve head image at diagnosis for baseline documentation (for
example, a stereoscopic optic nerve head image or OCT). [2009, amended 2017]
1.2.5 After referral, consider an early assessment appointment when there is clinical
concern based on the information provided. [2017]
1.2.6 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. [2017]
1.3 Standard practice for all assessments
1.3.1 Ensure that all of the following are made 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 which could affect drug choice
current systemic and topical medication
glaucoma medication record
drug allergies and intolerances. [2009]
1.3.2 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). [2009]
1.3.3 Ensure that all machines and measurement instruments are calibrated regularly
according to the manufacturers' instructions. [2009]
1.4 Reassessment
Reassessment tests
1.4.1 At each assessment, offer the following tests to people with COAG, people
suspected of having COAG and people with OHT:
Goldmann applanation tonometry (slit lamp mounted)
anterior segment slit lamp examination with van Herick peripheral anterior chamber
depth assessment when clinically indicated. [2017]
1.4.2 When clinically indicated, repeat gonioscopy, for example, where a previous
examination has been inconclusive or where there is suspicion of a change in
clinical status of the anterior chamber angle. [2017]
1.4.3 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 tables 2 and 3 for recommended reassessment intervals). [2009,
amended 2017]
1.4.4 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 tables 1 and 2 for recommended reassessment
intervals). [2009, amended 2017]
1.4.5 When a visual field defect has previously been detected, use the same
measurement strategy for each visual field assessment. [2009]
1.4.6 When clinically indicated, repeat assessment of the optic nerve head (for
example, stereoscopic slit lamp biomicroscopy or imaging). [2017]
1.4.7 When a change in optic nerve head status is detected by stereoscopic slit lamp
biomicroscopy, obtain a new optic nerve head image for the person's records to
provide a fresh benchmark for future assessments. [2009]
1.4.8 When an adequate view of the optic nerve head and surrounding area is
unavailable at reassessment, people should have their pupils dilated before
stereoscopic slit lamp biomicroscopy or optic nerve head imaging is repeated.
[2009]
When to reassess
People with CO
COAAG, suspected CO
COAAG and OHT
1.4.9 At each assessment, re-evaluate risk of conversion to COAG and risk of sight
loss to set time to next assessment. [2017]
1.4.10 At each assessment, ask about general health and, if appropriate, factors
affecting adherence to treatment, including cognitive impairment and any
treatment side effects. [2017]
People with tr
treated
eated OHT (baseline IOP 24 mmHg or mor
moree) and a normal optic nerv
nervee head
and visual field at most rrecent
ecent assessment
1.4.11 For people with treated OHT (baseline IOP of 24 mmHg or more) and a normal
optic head and visual field at the most recent assessment:
use clinical judgement to assess control of IOP and risk of conversion to COAG, and
reassess according to table 1. [2017]
Table 1 Time to ne
next
xt assessment for people being treated for OHT
Con
Convversion from OHT to Control of Time to next assessment1
next
CO
COA
AG IOP
Not detected or uncertain No Review management plan and reassess between 1

conversion2 and 4 months
Uncertain conversion2 Yes Reassess between 6 and 12 months
No conversion detected Yes Reassess between 18 and 24 months
Conversion No or yes See recommendations on the diagnosis and

reassessment of COAG
1
Use clinical judgement to decide when the next appointment should take place within the
recommended interval.
2
Uncertain conversion includes having insufficient accurate information (perhaps because the
person was unable to participate in the assessment).
People with suspected CO

COAAG
1.4.12 For people with suspected COAG:
use clinical judgement to assess control of IOP and risk of conversion to COAG (optic
nerve head damage and visual field defect), and
Table 2 Time to ne
next
xt assessment for people with suspected CO
COA
AG
Con
Convversion to CO
COA
AG Control of Time to next assessment1
next
IOP
Not detected or uncertain No Review management plan and reassess between 1

conversion2 and 4 months
Uncertain conversion2 Yes Reassess between 6 and 12 months
No conversion detected Yes Reassess between 12 and 18 months
Conversion No or yes See recommendations on the diagnosis and

reassessment of COAG
1
2
Uncertain conversion includes having insufficient accurate information (perhaps because the
person was unable to participate in the assessment).
People with CO
COAAG
1.4.13 For people with COAG:
use clinical judgement to assess risk of COAG progression to sight loss, and
Table 3 Time to ne
next
xt assessment for people with CO
COA
AG
Progression of CO
COA
AG Control of Time to next assessment1
next
IOP
Not detected No Review treatment plan and reassess between

1 and 4 months
Uncertain progression2 or No Review treatment plan and reassess between

progression 1 and 2 months
No progression detected and low Yes Reassess between 12 and 18 months

clinical risk
No progression detected and high Yes Reassess between 6 and 12 months

clinical risk
Uncertain progression2 or Yes Review treatment plan and reassess between

progression 2 and 6 months
1
2
Uncertain progression includes having insufficient accurate information (perhaps because
the person was unable to participate in the assessment).
Discharge back to primary care
1.4.14 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. [2017]
1.4.15 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. [2017]
1.5 Treatment
1.5.1 Take into account any cognitive and physical impairments when making
decisions about management and treatment. [2017]
1.5.2 Check that there are no relevant comorbidities or potential drug interactions
before offering pharmacological treatment. [2009]
Treatment for people with OHT
1.5.3 Offer a generic prostaglandin analogue (PGA)[ ] to people with IOP of 24 mmHg
3
or more (OHT) if they are at risk of visual impairment within their lifetime (see
recommendation 1.2.6). [2017]
1.5.4 Do not offer treatment to people with OHT who are not at risk of visual
impairment in their lifetime. Advise people to continue regular visits to their
primary eye care professional, at clinically appropriate intervals. [2017]
1.5.5 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, if available, and if this is not tolerated, offer a
beta-blocker. If none of these options are tolerated, offer non-generic PGA,
carbonic anhydrase inhibitors, sympathomimetics, miotics or a combination of
treatments. [2017]
1.5.6 Offer a drug from another therapeutic class (beta-blocker, carbonic anhydrase
inhibitor[ ] or sympathomimetic) to people with an IOP of 24 mmHg or more
4
whose current treatment is not reducing IOP sufficiently to prevent the risk of
progression to sight loss. Topical drugs from different therapeutic classes may
be needed at the same time to control IOP. [2009, amended 2017]
1.5.7 Refer people whose IOP cannot be reduced sufficiently with pharmacological
treatment to prevent the risk of progression to sight loss to a consultant
ophthalmologist to discuss other options. [2009]
1.5.8 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. [2009,
amended 2017]
Treatment for people with suspected CO

COA
AG
1.5.9 Do not offer treatment to people with suspected COAG and IOP less than
24 mmHg. Advise people to continue regular visits to their primary eye care
professional, at clinically appropriate intervals. [2017]
1.5.10 Offer a generic PGA[ ] to people with suspected COAG and IOP of 24 mmHg or
3
more, in line with the recommendations on treatment for people with OHT.
[2017]
Stopping treatment for people with OHT or suspected CO

COA
AG
1.5.11 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. [2009]
Treatment for people with CO

COA
AG
1.5.12 Offer a generic PGA[ ] to people with COAG. [2017]

3
1.5.13 Offer people with advanced COAG, surgery with pharmacological augmentation
(MMC[ ]) as indicated. Offer them information on the risks and benefits
5
associated with surgery. [2009, amended 2017]
1.5.14 Offer people who present with advanced COAG and who are listed for surgery,
interim treatment with a generic PGA[ ]. [2009, amended 2017]
3
1.5.15 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 drug. [2009]
1.5.16 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. If
adherence and eye drop instillation technique are satisfactory offer 1 of the
following:
a drug from another therapeutic class (a beta-blocker, carbonic anhydrase inhibitor[ ] or 4
sympathomimetic); topical drugs from different therapeutic classes may be needed at

the same time to control IOP
laser trabeculoplasty
surgery with pharmacological augmentation (MMC[ ]) as indicated.

5
If the drug treatment option is chosen, after trying drugs from 2 therapeutic classes,
consider offering surgery with pharmacological augmentation (MMC[ ]) as indicated or 5
laser trabeculoplasty. [2009, amended 2017]
1.5.17 Offer surgery with pharmacological augmentation (MMC[ ]) as indicated to 5
people with COAG who are at risk of progressing to sight loss despite
treatment. Offer them information on the risks and benefits associated with
surgery. [2009, amended 2017]
1.5.18 Consider offering people with COAG who cannot tolerate a treatment:
a drug from another therapeutic class (a beta-blocker, carbonic anhydrase inhibitor[ ] or 4
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 trying drugs from 2 therapeutic classes, consider offering surgery with
pharmacological augmentation (MMC[ ]) as indicated or laser trabeculoplasty. [2009,
5
amended 2017]
1.5.19 After surgery offer people with COAG whose IOP has not been reduced
sufficiently to prevent the risk of progression to sight loss 1 of the following:
pharmacological treatment; topical drugs from different therapeutic classes may be

needed at the same time to control IOP
further surgery
laser trabeculoplasty or cyclodiode laser treatment. [2009, amended 2017]
1.5.20 Offer people with COAG who prefer not to have surgery or for whom surgery is
not suitable:
pharmacological treatment; topical drugs from different therapeutic classes may be

needed at the same time to control IOP
laser trabeculoplasty or cyclodiode laser treatment. [2009, amended 2017]
1.6 Organisation of care
1.6.1 Refer people with suspected optic nerve damage or repeatable visual field
defect, or both, to a consultant ophthalmologist for consideration of a definitive
diagnosis and formulation of a management plan. [2009]
1.6.2 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. [2009, amended 2017]
1.6.3 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. [2017]
1.6.4 Healthcare professionals involved in the diagnosis of OHT and COAG suspect
status and preliminary identification of COAG should be trained in case
detection and referral refinement and be able to identify abnormalities based on
relevant clinical tests and assessments. They should understand the principles
of diagnosis of OHT and COAG and be able to perform and interpret all of the
following:
medical and ocular history
differential diagnosis
standard automated perimetry (central thresholding test)
central supra-threshold perimetry
stereoscopic slit lamp biomicroscopic examination of anterior segment
examination of the posterior segment using a slit lamp binocular indirect

ophthalmoscopy
gonioscopy
van Herick peripheral anterior chamber depth assessment
CCT measurement. [2009]
1.6.5 People with OHT, suspected COAG or COAG should have monitoring and
treatment from a trained healthcare professional who has all of the following:
a specialist qualification
relevant experience
ability to detect a change in clinical status. [2009, amended 2017]
1.6.6 Healthcare professionals involved in the monitoring and treatment of OHT,

suspected COAG and established COAG should be trained to make
management decisions on all of the following:
risk factors for conversion to COAG
coexisting pathology
risk of sight loss
monitoring and detecting a change in clinical status (for example, visual field changes,
stereoscopic slit lamp biomicroscopic examination of anterior segment and posterior
segment)
pharmacology of IOP-lowering drugs
treatment changes for COAG, suspected COAG and OHT (with consideration given to
relevant contraindications and interactions). [2009]
1.6.7 People with a confirmed diagnosis of OHT or suspected COAG and who have an
established management plan may have monitoring (but not treatment) from a
suitably trained healthcare professional with knowledge of OHT and COAG,
relevant experience and ability to detect a change in clinical status. The
healthcare professional should be able to perform and interpret all of the
following:
standard automated perimetry (central thresholding test)
central supra-threshold perimetry (this visual field strategy may be used for
monitoring OHT or suspected COAG when the visual field is normal)
stereoscopic slit lamp biomicroscopic examination of the anterior segment
van Herick peripheral anterior chamber depth assessment
examination of the posterior segment using slit lamp binocular indirect

ophthalmoscopy. [2009]
1.6.8 Healthcare professionals who diagnose, treat or monitor independently of

consultant ophthalmologist supervision should take full responsibility for the
care they provide. [2009]
1.7 Providing information
1.7.1 Offer people the opportunity to discuss their diagnosis, referral, prognosis,
treatment and discharge, and provide them with relevant information in an
accessible format at initial and subsequent visits. This may include information
on the following:
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
that glaucoma can run in families and that family members may wish to be tested for
the condition
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
take an active part in decision-making (see NICE's guideline on medicines
optimisation)
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)
the eye clinic liaison officer (ECLO)
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. [2009, amended 2017]
Terms used in this guideline
CO
COA
AG and related conditions
These include COAG, OHT and suspected COAG.
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.
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.
Primary e
eyye care professionals
These include optometrists, GPs with a special interest in ophthalmology and community
orthoptists.
Referr
Referral
al filtering
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'.
Referr
Referral
al 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. 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 organisation of care. 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.
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.
Sight loss
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 unware of a problem. Sight loss may
progress to visual impairment and eventually become symptomatic.
Sight test
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
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.
[1]
See Royal College of Ophthalmologists' Ophthalmic Services Guidance.
[2]
See Minimise transmission risk of CJD and vCJD in healthcare settings.
[3]
At the time of publication (November 2017), not all generic PGAs had a UK marketing
authorisation for first-line treatment. The prescriber should follow relevant professional guidance,
taking full responsibility for the decision. Informed consent should be obtained and documented.
See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for
further information.
[4]
At the time of publication (November 2017), some carbonic anhydrase inhibitors were licensed
for use only when beta-blockers were not tolerated or were contraindicated. The prescriber should
follow relevant professional guidance, taking full responsibility for the decision. Informed consent
should be obtained and documented. See the General Medical Council's Prescribing guidance:
prescribing unlicensed medicines for further information.
[5]
At the time of publication (November 2017), MMC did not have a UK marketing authorisation for
this indication. The prescriber should follow relevant professional guidance, taking full
responsibility for the decision. Informed consent should be obtained and documented. See the
General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further
information.
Putting this guideline into pr

practice
actice
NICE has produced tools and resources to help you put this guideline into practice.
Putting recommendations into practice can take time. How long may vary from guideline to
guideline, and depends on how much change in practice or services is needed. Implementing change
is most effective when aligned with local priorities.
Changes recommended for clinical practice that can be done quickly – like changes in prescribing
practice – should be shared quickly. This is because healthcare professionals should use guidelines
to guide their work – as is required by professional regulating bodies such as the General Medical
and Nursing and Midwifery Councils.
Changes should be implemented as soon as possible, unless there is a good reason for not doing so
(for example, if it would be better value for money if a package of recommendations were all
implemented at once).
Different organisations may need different approaches to implementation, depending on their size
and function. Sometimes individual practitioners may be able to respond to recommendations to
improve their practice more quickly than large organisations.
Here are some pointers to help organisations put NICE guidelines into practice:
1. Raise aawareness
wareness through routine communication channels, such as email or newsletters, regular
meetings, internal staff briefings and other communications with all relevant partner organisations.
Identify things staff can include in their own practice straight away.
2. Identify a lead with an interest in the topic to champion the guideline and motivate others to
support its use and make service changes, and to find out any significant issues locally.
3. Carry out a baseline assessment against the recommendations to find out whether there are
gaps in current service provision.
4. Think about what data yyou

ou need to measure impro
improvvement and plan how you will collect it. You
may want to work with other health and social care organisations and specialist groups to compare
current practice with the recommendations. This may also help identify local issues that will slow or
prevent implementation.
5. De
Devvelop an action plan
plan, with the steps needed to put the guideline into practice, and make sure it
is ready as soon as possible. Big, complex changes may take longer to implement, but some may be
quick and easy to do. An action plan will help in both cases.
6. For vvery
ery big changes include milestones and a business case, which will set out additional costs,
savings and possible areas for disinvestment. A small project group could develop the action plan.
The group might include the guideline champion, a senior organisational sponsor, staff involved in
the associated services, finance and information professionals.
7. Implement the action plan with oversight from the lead and the project group. Big projects may
also need project management support.
8. Re
Review
view and monitor how well the guideline is being implemented through the project group.
Share progress with those involved in making improvements, as well as relevant boards and local
partners.
NICE provides a comprehensive programme of support and resources to maximise uptake and use
of evidence and guidance. See our into practice pages for more information.
Also see Leng G, Moore V, Abraham S, editors (2014) Achieving high quality care – practical
experience from NICE. Chichester: Wiley.
Conte
Context
xt
The scope of this NICE guideline on diagnosing and managing chronic open angle glaucoma has
been extended to cover referral. This includes the most effective service models for referral
filtering schemes (repeat measures, enhanced case-finding and referral refinement), the tests to be
used for finding people with chronic open angle glaucoma, suspected chronic open angle glaucoma
and ocular hypertension (OHT), and thresholds for onward referral. We have also updated the
guidance on tests for diagnosis and reassessment, pharmacological treatments for lowering
intraocular pressure and preserving visual field, and reassessment intervals which depend on
prognosis.
The update has provided an opportunity to re-evaluate the clinical effectiveness, cost effectiveness
and indications for treating OHT. Knowledge of corneal thickness is no longer needed to decide
whether or not to treat OHT and a single threshold of 24 mmHg is now recommended for both
onward referral and treatment. Changes in the costs of pharmacological treatments,
acknowledgement of short- and long-term variations in intraocular pressure and the uneven
relationship between rising pressure and increased risk have allowed a simplification of the
indications for OHT treatment.
Control of intraocular pressure remains critical to the therapeutic approach, with intensity of
treatment and ongoing management being guided by disease severity and progression as shown by
visual field change, morphological change in the optic disc, and the likelihood of progressive sight
loss. Reassessment at each visit is emphasised, encouraging flexible clinical judgement about the
frequency of visits and options for treatment, including stopping treatment when the perceived
risk to a sighted lifetime is low.
Where fresh evidence was not found the guideline has not been updated, that is, accuracy of visual
field tests, surgical interventions, laser procedures and information, education and support needed
for adherence to treatment.
More information
You can also see this guideline in the NICE Pathway on glaucoma.
To find out what NICE has said on topics related to this guideline, see our web page on eye
conditions.
See also the guideline committee's discussion and the evidence reviews (in the full guideline),
and information about how the guideline was developed, including details of the committee.
Recommendations for research
The guideline committee has made the following recommendations for research.
1 Risk tools to identify risk of developing COAG and risk of sight loss
What is the predictive value of risk tools for identifying people in the community who are at
increased risk of developing chronic open angle glaucoma (COAG) and identifying people with
COAG who are at increased risk of sight loss?
Wh
Whyy this is important
Most cases of COAG are first detected by case-finding in community optometry after a sight test
(with or without repeat measures, enhanced case-finding, or referral refinement). Identifying at
case-finding which people are at high risk of conversion to COAG is important for guiding decisions
about monitoring, treatment and referral. However, current evidence on the sensitivity and
specificity of risk tools for developing COAG is of moderate-to-low quality, with all studies having a
high or very high risk of bias. There was no evidence on cost effectiveness.
Similarly, a risk tool that identifies people with COAG who are at risk of progression to sight loss
would be useful for both patients and healthcare professionals. People at higher risk of sight loss
could have more frequent testing and perhaps more intensive treatment, whereas people at lower
risk could have less frequent assessments and potentially less intensive treatment.
2 Treatment for people with an IOP of 22 or 23 mmHg
What is the clinical and cost effectiveness of treating an intraocular pressure (IOP) of 22 or
23 mmHg in people with normal optic discs and visual fields?
Wh
The only proven intervention for preventing and controlling glaucoma is lowering IOP. It has been
widely accepted that the upper limit of statistically normal IOP is 21 mmHg. This was also accepted
as the threshold for treatment, and most treatment studies aimed to achieve this target or a
reduction in IOP of between 25% and 35% from baseline. However, more recently the Ocular
Hypertension Treatment Study (OHTS) enrolled people with an IOP between 24 mmHg and
32 mmHg, but without glaucomatous optic nerve damage, to receive treatment or no treatment.
The results showed a reduction in 5-year incidence of very early glaucoma (either optic disc or
visual field changes) from 9.5% in people not receiving treatment to 4.4% in those having
treatment. This leaves an area of uncertainty about treatment for people with an IOP above
21 mmHg but below 24 mmHg. There are about 1.8 million people in the UK with an IOP of 22 or
23 mmHg. The costs associated with management in these people are sufficient to make this
question of national importance.
3 An instrument to measure quality of life in people with glaucoma
What instrument should be used to measure health related quality of life in people with glaucoma?
Wh
Quality of life is the most important overall measure of treatment effect for patients as it measures
their life experience and how their life experience is affected by interventions. Patient-reported
outcome measures (PROM) are used for informing patients of the value of interventions and may
affect their treatment choices. They also offer a tool for audit or service evaluation of glaucoma
services, and for designing glaucoma trials.
However, uncertainty exists as to which PROM instrument should be used to measure outcomes of
glaucoma interventions. A suitable instrument would be helpful to inform patients, healthcare
professionals and policy makers about the effectiveness of glaucoma interventions. Identifying a
valid and responsive PROM for measuring glaucoma outcomes would allow this instrument to be
adopted in future clinical trials and glaucoma audits and would ensure meaningful comparisons
between different interventions.
4 Optical coherence tomography for glaucoma
What is the effectiveness and cost effectiveness of optical coherence tomography (OCT) for
diagnosing and monitoring glaucoma?
Wh
Glaucoma is an age-related chronic condition and the second leading cause of blindness in the UK.
Once detected, glaucoma care usually takes place in hospital eye services, where patients are
monitored for the rest of their life. There are over 1 million visits per year for glaucoma care in the
NHS in England. This is predicted to increase substantially as a result of an ageing population and
better detection in the community.
For diagnosis and monitoring, patients have an examination of the optic nerve and a review of
visual field test results. Visual field testing has potential limitations: there is a learning effect and
variability, it involves considerable patient effort, it is influenced by comorbidities, and in some

people results are not reliable. Automated imaging with OCT overcomes many of these limitations.
OCT is an imaging technology that has evolved over the past 2 decades and is currently used in all
NHS departments for the diagnosis and management of retinal diseases. However, current use of
OCT and imaging technologies in glaucoma is highly variable.
It is possible the addition of OCT for diagnosing and monitoring glaucoma may enable earlier
detection of disease and progression than when visual field testing is used alone. This could lead to
escalation of treatment with less visual loss and blindness. However, it is possible that OCT may
detect structural changes that will not be translated into functional loss, and may lead to
unnecessary treatment. Overtreatment is likely to be associated with side effects and increased
healthcare costs.
5 Referral filtering
What is the effectiveness and cost effectiveness of the different models for glaucoma filtering
(pathways from case-finding to assessment in secondary ophthalmic care) for detecting glaucoma
and glaucoma-related conditions (ocular hypertension and suspected glaucoma)?
Wh
Routine optometric sight testing has poor sensitivity and specificity for detecting glaucoma and
glaucoma-related conditions, resulting in a high percentage of false positive referrals to secondary
care. These are costly for commissioners, cause unnecessary anxiety for patients and are a burden
for secondary care. A variety of referral filtering models have been developed to improve the
accuracy of referrals. These include 'repeat measures' schemes in which IOP measurement or
visual field assessments, or both, are repeated at a separate visit; 'enhanced case-finding' referral
enhancement schemes in which IOP measurements are repeated, detailed disc assessment is
carried out and visual fields are performed with automated perimetry; 'referral refinement'
schemes, which require tests sufficient for the diagnosis of ocular hypertension and suspected
COAG, including gonioscopy, and the interpretation of these clinical findings.
Each scheme requires different levels of healthcare training and qualifications. Investment in
equipment may also be needed to set up these services, and professionals would expect
remuneration for providing these models of care.
It is unclear which of these models is the most accurate (sensitive and specific) and which is most
cost effective. Evidence is therefore needed so that commissioners can commission the best
services that allow accurate referral to secondary care for glaucoma assessment.
Update information
No
Novvember 2017: This guideline is an update of NICE guideline CG85 (published April 2009) and
replaces it.
New recommendations have been added for case-finding, diagnosis, reassessment and treatment.
These are marked as: [2017]

[2017].
Recommendations that have been changed
Amended recommendation wording ((change

change to meaning)
Recommendation in 2009 guideline Recommendation in Reason for change

current guideline
Obtain an optic nerve head image at Obtain an optic nerve Clarification added that this
diagnosis for baseline head image at diagnosis image may be acquired by a
documentation. (1.1.4) for baseline stereoscopic optic nerve
documentation (for head image (leaving it open
example, a stereoscopic to either biomicroscopy slit
optic nerve head image or lamp examination or stereo
OCT). (1.2.4) photography) or OCT,
whichever is more readily
available at the time of
diagnosis.
Offer standard automated When clinically indicated, The original

perimetry (central thresholding repeat visual field testing recommendation contained
test) to all people who have using standard 2 separate instructions (1
established COAG and those automated perimetry for people with established
suspected of having visual field (central thresholding test) COAG and those having
defects who are being investigated for people with COAG initial investigation for
for possible COAG. People with and those suspected of possible COAG, and 1 for
diagnosed OHT and those having visual field defects follow-up of people with an
suspected of having COAG whose who are being established diagnosis of
visual fields have previously been investigated for possible suspected COAG or OHT).
documented by standard COAG (see tables 2 and 3 These 2 instructions have
automated perimetry as being for recommended now been separated into 2
normal may be monitored using reassessment intervals). recommendations to
supra-threshold perimetry (see (1.4.3) improve clarity.
tables 4 and 5 for recommended
monitoring intervals). (1.2.5)
Offer standard automated When clinically indicated, As above, the original

perimetry (central thresholding repeat visual field testing recommendation contained
test) to all people who have using either a central 2 separate instructions (1
established COAG and those thresholding test or a for people with established
suspected of having visual field supra-threshold test for COAG and those having
defects who are being investigated people with OHT and initial investigation for
for possible COAG. People with those suspected of having possible COAG, and 1 for
diagnosed OHT and those COAG whose visual fields follow-up of people with an
suspected of having COAG whose have previously been established diagnosis of
visual fields have previously been documented by standard suspected COAG or OHT).
documented by standard automated perimetry as These 2 instructions have
automated perimetry as being being normal (see tables 1 now been separated into 2
normal may be monitored using and 2 for recommended recommendations to
supra-threshold perimetry (see reassessment intervals). improve clarity.
tables 4 and 5 for recommended (1.4.4) The original
monitoring intervals). (1.2.5) recommendation was
suggesting that for people
with OHT and COAG
suspects with normal visual
fields, it would be acceptable
to use the supra-threshold
test as opposed to the
superior central
thresholding test (CTT)
recommended for those
with established COAG.
However the committee
wished to clarify that the
CTT is also an option for this
population if it is clinically
available.
Offer alternative pharmacological Offer a drug from another Clarification that the drug
treatment (a prostaglandin therapeutic class (beta- should be from another
analogue, beta-blocker, carbonic blocker, carbonic therapeutic class when
anhydrase inhibitor or anhydrase inhibitor or switching to another
sympathomimetic) to treated sympathomimetic) to monotherapy and when
people with OHT or suspected people with an IOP of adding another drug. This
COAG whose IOP cannot be 24 mmHg or more whose clarification was considered
reduced sufficiently to prevent the current treatment is not important because
risk of progression to sight loss. reducing IOP sufficiently committee members were
More than one agent may be to prevent the risk of aware of inappropriate
needed concurrently to achieve progression to sight loss. switching through multiple
target IOP. (1.3.5) Topical drugs from examples of drugs from the
different therapeutic same class (for example,
classes may be needed at multiple PGA switches).
the same time to control
IOP. (1.5.6)
Offer a preservative-free Offer preservative-free High risk of conversion is no

preparation to people with OHT or eye drops to people who longer defined in the
suspected COAG and an allergy to have an allergy to guideline by IOP and CCT so
preservatives only if they are at high preservatives or people these parameters have been
risk of conversion to COAG (IOP with clinically significant removed from the
more than 25 and up to 32 mmHg and symptomatic ocular recommendation. Treatment
and CCT less than 555 micrometres, surface disease, but only adherence may be
or IOP more than 32 mmHg). (1.3.7) if they are at high risk of significantly affected by
conversion to COAG. both allergic and non-
(1.5.8) allergic reactions
(preservative toxicity).
Preservative toxicity is a
particular problem for
people with ocular surface
diseases so this group was
added to the
recommendation.
Offer people with advanced COAG Offer people with 5FU is no longer used as
surgery with pharmacological advanced COAG, surgery standard practice during
augmentation (MMC or 5-FU) as with pharmacological surgical treatment and
indicated. Offer them information augmentation (MMC) as postoperative care.
on the risks and benefits associated indicated. Offer them
with surgery. (1.4.3) information on the risks
and benefits associated
with surgery. (1.5.13)
Offer people who present with Offer people who present Generic PGAs are now
advanced COAG and who are listed with advanced COAG and recommended in the
for surgery interim treatment with a who are listed for surgery, guideline for first-line
prostaglandin analogue. (1.4.4) interim treatment with a treatment.
PGA prescribed
generically. (1.5.14)
Check the person's adherence to Ask about adherence to Clarification that the drug
their treatment and eye drop treatment and check the should be from another
instillation technique in people with eye drop instillation therapeutic class when
COAG whose IOP has not been technique in people with switching to another
reduced sufficiently to prevent the COAG whose IOP has not monotherapy and when
risk of progression to sight loss been reduced sufficiently adding another drug. 5FU is
despite pharmacological treatment. to prevent the risk of no longer used as standard
If adherence and eye drop progression to sight loss practice during surgical
instillation technique are despite pharmacological treatment and
satisfactory offer one of the treatment. If adherence postoperative care.
following: and eye drop instillation
alternative pharmacological technique are
treatment (a prostaglandin satisfactory offer 1 of the
analogue, beta-blocker, carbonic following:
anhydrase inhibitor or a drug from another
sympathomimetic); more than therapeutic class (a
one agent may be needed beta-blocker, carbonic
concurrently to achieve target anhydrase inhibitor or
IOP sympathomimetic);
topical drugs from
laser trabeculoplasty different therapeutic
classes may be needed
surgery with pharmacological
at the same time to
augmentation (MMC or 5-FU) as
control IOP
indicated.
laser trabeculoplasty
If the pharmacological treatment
option is chosen, after trying two surgery with
alternative pharmacological pharmacological
treatments consider offering augmentation (MMC)
surgery with pharmacological as indicated.
augmentation (MMC or 5-FU) as
indicated or laser trabeculoplasty. If the drug treatment
(1.4.6) option is chosen, after
trying drugs from 2
therapeutic classes,
consider offering surgery
with pharmacological
augmentation (MMC) as
indicated or laser
trabeculoplasty. (1.5.16)
Offer surgery with pharmacological Offer surgery with 5FU is no longer used as
augmentation (MMC or 5-FU) as pharmacological standard practice during
indicated to people with COAG who augmentation (MMC) as surgical treatment and
are at risk of progressing to sight indicated to people with postoperative care.
loss despite treatment. Offer them COAG who are at risk of
information on the risks and progressing to sight loss
benefits associated with surgery. despite treatment. Offer
(1.4.7) them information on the
risks and benefits
associated with surgery.
(1.5.17)
Consider offering people with Consider offering people Clarification that the drug
COAG who are intolerant to a with COAG who cannot should be from another
prescribed medication: tolerate a treatment: therapeutic class when
alternative pharmacological a drug from another switching to another
treatment (a prostaglandin therapeutic class (a monotherapy. Treatment
analogue, beta-blocker, carbonic beta-blocker, carbonic adherence may be
anhydrase inhibitor or anhydrase inhibitor or significantly affected by
sympathomimetic) or sympathomimetic) or both allergic and non-
allergic reactions
a preservative-free preparation preservative-free eye (preservative toxicity).
if there is evidence that the drops if there is Preservative toxicity is a
person is allergic to the evidence that the particular problem for
preservative. person is allergic to people with ocular surface
the preservative or has diseases so this group was
After trying two alternative clinically significant added to the
pharmacological treatments and symptomatic recommendation.
consider offering surgery with ocular surface disease 5FU is no longer used as
pharmacological augmentation
standard practice during
(MMC or 5-FU) as indicated or laser After trying drugs from 2
surgical treatment and
trabeculoplasty. (1.4.8) therapeutic classes,
postoperative care.
consider offering surgery
with pharmacological
augmentation (MMC) as
indicated or laser
trabeculoplasty. (1.5.18)
After surgery offer people with After surgery offer Clarification that the drug
COAG whose IOP has not been people with COAG whose should be from another
reduced sufficiently to prevent the IOP has not been reduced therapeutic class when
risk of progression to sight loss one sufficiently to prevent the switching to another
of the following: risk of progression to monotherapy and when
pharmacological treatment (a sight loss 1 of the adding another drug.
prostaglandin analogue, following:
beta-blocker, carbonic anhydrase pharmacological
inhibitor or sympathomimetic); treatment; topical
more than one agent may be drugs from different
needed concurrently to achieve therapeutic classes
target IOP may be needed at the
same time to control
further surgery IOP
laser trabeculoplasty or further surgery

cyclodiode laser treatment.
(1.4.9) laser trabeculoplasty
or cyclodiode laser
treatment. (1.5.19)
Offer people with COAG who Offer people with COAG Clarification that the drug
prefer not to have surgery or who who prefer not to have should be from another
are not suitable for surgery: surgery or for whom therapeutic class when
pharmacological treatment (a surgery is not suitable: switching to another
prostaglandin analogue, pharmacological monotherapy and when
beta-blocker, carbonic anhydrase treatment; topical adding another drug.
inhibitor or sympathomimetic); drugs from different
more than one agent may be therapeutic classes
needed concurrently to achieve may be needed at the
target IOP same time to control
IOP
laser trabeculoplasty or
cyclodiode laser treatment. laser trabeculoplasty
or cyclodiode laser
(1.4.10) treatment. (1.5.20)
Offer people the opportunity to Offer people the Amended to indicate that
discuss their diagnosis, prognosis opportunity to discuss people should have the
and treatment, and provide them their diagnosis, referral, opportunity to discuss
with relevant information in an prognosis, treatment and referral, and discharge, and
accessible format at initial and discharge, and provide that patient information
subsequent visits. This may include them with relevant should also include:
information on the following: information in an reassurance that most
their specific condition (OHT, accessible format at people having treatment
suspected COAG and COAG), its initial and subsequent for COAG will have a
life-long implications and their visits. This may include good quality of life
prognosis for retention of sight information on the
following: reference to the eye
that COAG in the early stages clinic liaison officer
their specific condition
and OHT and suspected COAG (ECLO) as these now
(OHT, suspected
are symptomless available in many clinics
COAG and COAG), its
life-long implications
that most people treated for reference to support
and their prognosis for
COAG will not go blind organisations.
retention of sight
that once lost, sight cannot be
that COAG in the early
recovered
stages and OHT and
that glaucoma can run in families suspected COAG are
and that family members may symptomless
wish to be tested for the disease
that most people
the importance of the person's having treatment for
role in their own treatment – for COAG will have good
example, the ongoing regular quality of life and not
application of eye drops to go blind
preserve sight
that once lost, sight
the different types of treatment cannot be recovered
options, including mode of
that glaucoma can run
action, frequency and severity of
in families and that
side effects, and risks and
family members may
benefits of treatment, so that
wish to be tested for
people are able to be active in
the condition
the decision-making process
how to apply eye drops, including the importance of the

technique (punctal occlusion and person's role in their
devices) and hygiene (storage) own treatment – for
example, the ongoing
the need for regular monitoring regular application of
as specified by the healthcare eye drops to preserve
professional sight
methods of investigation during the different types of

assessment treatment options,
including mode of
how long each appointment is
action, frequency and
likely to take and whether the
severity of side effects,
person will need any help to
and risks and benefits
attend (for example, driving soon
of treatment, so that
after pupil dilatation would be
people are able to take
inadvisable)
an active part in
support groups decision-making
compliance aids (such as how to apply eye

dispensers) available from their drops, including
GP or community pharmacist technique (punctal
occlusion and devices)
Letter of Vision Impairment and hygiene (storage)
(LVI), Referral of Vision
Impairment (RVI) and Certificate the need for regular
of Vision Impairment (CVI) monitoring as
registration specified by the
healthcare
Driver and Vehicle Licensing professional
Agency (DVLA) regulations.
(1.6.1) 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)
the eye clinic liaison

officer (ECLO)
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.
(1.7.1)
ISBN: 978-1-4731-2713-5
Accreditation

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© NICE 2018. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-of-

Commissioners and providers have a responsibility to promote an environmentally sustainable

Who is it for? .................................................................................................................................................................................... 4

1.1 Case-finding ............................................................................................................................................................................. 5

1.3 Standard practice for all assessments ............................................................................................................................ 7

1.5 Treatment .................................................................................................................................................................................. 12

1.6 Organisation of care .............................................................................................................................................................. 15

1.7 Providing information........................................................................................................................................................... 18

Terms used in this guideline ....................................................................................................................................................... 19

Putting this guideline into practice ........................................................................................................................... 22

Recommendations for research ................................................................................................................................. 25

2 Treatment for people with an IOP of 22 or 23 mmHg ................................................................................................. 25

3 An instrument to measure quality of life in people with glaucoma ........................................................................ 26

4 Optical coherence tomography for glaucoma ................................................................................................................ 26

Recommendations that have been changed ....................................................................................................................... 29

This guideline replaces CG85.

This guideline is the basis of QS7.

Commissioners and providers of eye care services

intraocular pressure (IOP) measurement using Goldmann-type applanation tonometry

24 mmHg or more, unless clinical circumstances indicate urgent or emergency

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. [2017]

These recommendations are for people planning and pro

visual field assessment using standard automated perimetry (central thresholding

IOP measurement using Goldmann applanation tonometry (slit lamp mounted)

peripheral anterior chamber configuration and depth assessments using gonioscopy

central corneal thickness (CCT) measurement. [2017]

1.2.2 Adopt professional[ ]/Department of Health[ ] guidance to reduce the risk of

transmitting infective agents via contact tonometry or gonioscopy. [2009]

life expectancy. [2017]

1.3 Standard practice for all assessments

records of past medical history which could affect drug choice

current systemic and topical medication

glaucoma medication record

drug allergies and intolerances. [2009]

1.3.2 Use alternative methods of assessment if clinical circumstances rule out

Goldmann applanation tonometry (slit lamp mounted)

reassess according to table 1. [2017]

Not detected or uncertain No Review management plan and reassess between 1

Uncertain conversion2 Yes Reassess between 6 and 12 months

No conversion detected Yes Reassess between 18 and 24 months

Conversion No or yes See recommendations on the diagnosis and

People with suspected CO

1.4.12 For people with suspected COAG:

reassess according to table 2. [2017]

Not detected or uncertain No Review management plan and reassess between 1

Uncertain conversion2 Yes Reassess between 6 and 12 months

No conversion detected Yes Reassess between 12 and 18 months

Conversion No or yes See recommendations on the diagnosis and

1.4.13 For people with COAG:

reassess according to table 3. [2017]

Not detected No Review treatment plan and reassess between

Uncertain progression2 or No Review treatment plan and reassess between

No progression detected and low Yes Reassess between 12 and 18 months

No progression detected and high Yes Reassess between 6 and 12 months

Uncertain progression2 or Yes Review treatment plan and reassess between

Discharge back to primary care