Glaucoma: diagnosis and management

Context

The scope of this NICE guideline on diagnosis and management of glaucoma was extended to cover referral in 2017. This included 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 COAG and ocular hypertension (OHT), and thresholds for onward referral. In 2017, the guidance was also updated on tests for diagnosis and reassessment, pharmacological treatments for lowering intraocular pressure (IOP) and preserving visual field, and reassessment intervals, which depend on prognosis.

The 2017 update 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 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 IOP and the uneven relationship between rising pressure and increased risk have allowed a simplification of the indications for OHT treatment.

Control of IOP remains critical to the therapeutic approach. Intensity of treatment and ongoing management are 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 lifetime risk of developing visual impairment is low.

Since the update in 2017, there has been new evidence on the use of 360° selective laser trabeculoplasty as a first-line treatment for OHT and COAG. Therefore, recommendations on treatment for people with OHT or COAG were updated.

Sections of the guideline on accuracy of visual field tests, surgical interventions, and information, education and support needed for adherence to treatment have not been updated because no new evidence was found.