Glaucoma: diagnosis and management

Excerpt

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 (COAG), 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 to achieve adherence to treatment.

Updating significant elements of the guideline has required an intensive effort from both the professional members of the National Guideline Centre and the guideline committee, who are thanked for their expertise, thoughtful work and in-depth discussions at and between guideline committee meetings.