How to achieve better outcomes in glaucoma patients with cataracts

Achieving better outcomes for glaucoma patients with cataracts was the theme of Specsavers and Glaucoma UKs’ Main Stage lecture on the Sunday of 100% Optical (2 March).

Giles Edmonds, clinical services director at Specsavers, and Paul Morris, the multiple’s director of professional advancement, were joined by consultant ophthalmic surgeon Nishani Amerasinghe for the presentation.

Amerasinghe is a former president of the UK and Éire Glaucoma Society.

Opening the lecture, Edmonds noted that glaucoma patients are often living with co-morbidities.

“In the next decade, I want to see an end to preventable blindness due to glaucoma, but as it stands, we are a very long way from achieving that,” he said.

“We know that glaucoma services are under a huge amount of pressure in the UK, with patients languishing on long and growing waiting lists, and we need urgent action now to prevent more people needlessly losing their sight,” Edmonds emphasised.

The session had been designed to demonstrate why it is “vital that we all work together to make sure that we can address the challenges around the growing demand for glaucoma services,” he said, as well as to share strategies for improving the detection of glaucoma and its management.

The wider picture

A political, economic, social and technological analysis can highlight where attention needs to be focused, Edmonds said.

Factors currently at work that have the potential to disrupt or influence the optometry profession include the political landscape in the UK and the rest of the world, Edmonds added, noting that trade tariffs are likely to cause instability in global supply chains.

The current UK Government came to power in July 2024 with a number of challenges including an economic blackhole, and the cost and size of national debt has continued to increase since then, he said.

Edmonds acknowledged the impact of the Darzi Report and the government’s purported ‘three big shifts’ in terms of healthcare, but added that these changes are likely to be “many, many years away from being implemented.”

The challenge of an ageing population continues, as does the impact of long NHS waiting lists, Edmonds said.

At the same time, he noted that the Royal College of Ophthalmologists has predicted a 44% increase in the need for glaucoma services by 2035.

This means that “we have got to develop pathways to be more patient-centric,” Edmonds believes.

Wales and Scotland are setting a good example, meaning “it’s England where we need to focus our lobbying,” he said.

Considering social and technological forces, Edmonds observed that more technology was on display at 100% Optical 2025 than he had ever seen before – but that it was “yet to impact waiting times.”

Artificial intelligence development remains complex and costly and new opportunities for eye care practitioners come with new challenges, he said, adding: “Together, we must bring about positive change. No one is going to do it for us.”

Key stakeholders must be influenced to prioritise care for chronic conditions, including glaucoma, Edmonds said.

He added that there being no clear eye care strategy for England means that government has been able to be quiet on its plans for the care of patients with chronic conditions.

MIGS as a golden opportunity for glaucoma care

Representing Glaucoma UK, Amerasinghe began by highlighting the conflict that optometrists might have when referring glaucoma patients: into the NHS, where they might find themselves on a long waiting list, or into an independent services provider, who might only be able to treat their cataracts.

Amerasinghe noted that glaucoma patients undergoing cataract surgery have a higher instance of spikes in their interocular pressure (IOP).

“We have to be careful with these patients,” she said.

One solution is minimally invasive glaucoma surgery (MIGS), Amerasinghe said.

She described MIGS as “the new gold standard” for care of these patients.

There are various types of MIGS, Amerasinghe noted, including trabecular stenting, trabecular dilation, and trabecular disruption.

She explained that there is a lot of long-term data supporting the quality of combined surgery for glaucoma and cataracts, including the HORIZON trial, which reported five-year results and saw that 66% of patients were medicine-free five years post-surgery.

“We now know that there is long-term good reduction in IOP, visual field data stabilisation, and [that] it is safe,” Amerasinghe said.

Quality of life can be improved through MIGS, she told attendees.

She also noted an Italian study, carried out in 2021, which demonstrated that MIGS is cost-effective.

There are various instances in which a patient could be considered suitable for the combined surgery, Amerasinghe said, noting particularly those with pen-angle glaucoma and those with IOP in the mid-teens.

Glaucoma surgery should be performed first in high risk or emergency situations, she advised.

She also cautioned practitioners to consider the outcome that patients should expect, and to manage expectations in terms of patients’ compliance and the impact on their ocular surface.

Referring to her opening question, on referrals, Amerasinghe emphasised that MIGS should be performed within a glaucoma specialist-led service.

“In the middle of this is the patient,” she reminded attendees.

She advised being conscious of the patient’s emotional wellbeing, as well as their physical health.

Glaucoma UK can support with this, including via their buddy service, she said.

Lack of engagement and poor adherence amongst high-risk groups, including those who have eye tests infrequently, are all issues when working to end preventable blindness from glaucoma, Amerasinghe added.

If not now, when?

Morris closed the session by calling on optometrists to push for the changes that they want to see.

Glaucoma is a “massive societal problem” and is placing a large burden on social care budgets, Morris told attendees.

He described glaucoma as one of the “basics the eye care sector hasn’t cracked.”

The challenge comes from detection being largely opportunistic rather than proactive, from the still-existing COVID-19 backlog, from an ageing population and from NHS waiting times, Morris said, as well as delays in follow-up and frequently rescheduled appointments.

We are in a dangerous time, when optometry is at risk of being “frozen out and not part of the solution,” he said – despite the profession having the ability to save millions of people from sight loss.

“It’s about having the right skills, it’s about having the right facilities, it’s about having the right equipment – but it’s also about having the right conversations,” Morris said.

When Morris began his career in optometry in the year 2000, he would never have expected to see independent prescribing clinics in Wales, he revealed.

He also noted that it took a decade from the lightbulb being invented to infrastructure being in place for it to actually be used, and that the fundus camera is very different today to the version of it that was first invented.

“We have all got to push in the right direction to get that infrastructure in place,” he said.

Digital platforms that enable the easy sharing of data with patients are vital, Morris said – and practice owners need to tell those developing these platforms exactly what their requirements are.

Optometry needs an upgrade in the technology available to it to bring it in line with ophthalmology, Morris said.

Addressiung the audience, he added: “The biggest push that it needs is sitting in front of me right now.”

Simple steps that optometrists can take in terms of glaucoma care include educating local GPs and pharmacists – asking them to hand out Glaucoma UK leaflets to their patients, or advising them on how to ask patients about drops, for example.

Most GPs and pharmacists know very little about glaucoma, Morris reminded attendees.

As 100% Optical was held at the start of Ramadan, he also noted that many patients might believe they could not take their glaucoma drops during the month.

This provides an opportunity for education via local radio and places of worship, he said.

Surveys also show a general lack of public awareness of glaucoma, with one quarter of people failing to get regular eye tests.

Morris noted that patient education should simplify and normalise the glaucoma treatment routine, address barriers to compliance, and build in regular reviews.

Speaking about addressing the issue of glaucoma care, Morris asked the question: “If not you, then who?”

He also noted that glaucoma will continue to be problem for the government, as it “continues to be a long-term problem for the people they represent.”

Visit the clinician section of the Glaucoma UK website here.

Lead image: Paul Morris, Nishani Amerasinghe and Giles Edmonds at 100% Optical 2025