NICE Glaucoma Guidelines
The National Institute for Health and Clinical Excellence (NICE) has issued guidelines on the diagnosis and management of chronic open angle glaucoma and ocular hypertension.
The AOP, ABDO and FODO strongly advise optometrists to take note of the NICE Guidelines when considering the referral of patients with signs of OHT. The AOP has issued separate advice for Scottish optometrists, backed by a legal opinion from an Edinburgh-based QC (see pdfs below).
NICE lays out very clearly who is at risk of glaucoma and what tests these patients need to have. It identifies OHT as a risk factor and defines what OHT is – pressures over 21, measured repeatedly on separate occasions, using slit lamp mounted Goldmann tonometry, when the CCT (corneal central thickness) is greater than 590nm. It states clearly that OHTs should be offered a number of defined tests (including gonio and pachymetry) and should be monitored (also using a defined set of tests, which are well beyond the requirements of GOS).
English and Welsh PCTs and Health Boards may not have the resources to cope with the numbers of referrals – many of which, because they will have had their pressures taken using NCT, will be false positives. Nevertheless, in the absence of funding to repeat pressures using Goldmann, the AOP believes strongly that optometrists have no choice other than to refer a patient who has a sign of ocular hypertension – e.g. pressures measured at over 21 mmHg, using whatever tonometer they choose.
To identify a sign of OHT and then not to act on it could be considered to be unprofessional, especially when the correct course of action has been well researched, by a panel of experts in the field, using evidence-based methods, and has been officially published by NICE. Some PCTs are asking optometrists to continue to refer as they did before the publication of NICE. However, such a PCT is avoiding its own responsibility for treating these patients. But it will not be indemnifying the optometrist for his or her lack of action. It hopes that the optometrist will take the responsibility that is rightfully its own.
PCTs do not have the power to insist that optometrists should not refer according to the NICE guidelines.
The full NICE Guidelines can be downloaded by clicking here.
The LOC SU has developed a pathway for glaucoma and OHT rapid referral which is available for LOCs to use in discussions with their PCTs and LHBs as they seek to implement NICE. It can be downloaded from the LOC Support Unit web site by clicking here
Joint Working Group issues referral guidance
The Joint Working Group, (made up of representatives from the College of Optometrists, The Royal College of Ophthalmologists, the AOP and FODO) have issued guidance on the referral of patients with suspected glaucoma or OHT. The guidance clarifies the referral criteria, including the use of non-contact tonometers, in this context. It relates to asymptomatic patients with suspected glaucoma only. Those with symptoms should be treated according to current protocols and patients suspected of having other previously undiagnosed conditions should be referred as appropriate. The guidance is available in pdf format at the end of this page.
The AOP is particularly happy to note that:
The guidance confirms that patients with IOPs measured at greater than 21 mmHg with any tonometer, including NCT, should be referred, except for patients over the age of 65, for whom there is more specific advice in the guidance.
The guidance acknowledges tacitly that visual fields are not a requirement for referral. The sentence “Where practitioners have determined that it is clinically necessary to perform a visual field assessment as part of particular eye examination, a copy of the visual field assessment should also be provided“ allows that there may be situations where a practitioner does not think it clinically necessary to perform a visual field assessment.
The AOP has endorsed this guidance and hopes that all optometrists, all ophthalmologists and all PCTs/LHBs will take heed.
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