NICE Glaucoma Guideline (NG81) – Key Points and Actions for Optical Professionals in Staffordshire
The revised “NICE Guideline Glaucoma: diagnosis and management” came into effect on 1 November 2017. The background to the new guideline is that around 10% of those registered as blind in the UK have glaucoma. We know that Chronic Open Angle Glaucoma (COAG) is often asymptomatic, with significant and irreparable damage to the optic nerve fibres by the time the disease is detected. Early diagnosis and treatment of people with glaucoma is crucial to avoiding blindness. This fact is an important driver for the update to the guidelines, with a focus on accurate and timely referrals.
For most community optometrists, the guideline on referral is the most relevant.The key points of the revised guideline for Staffordshire optical practitioners, and how it will affect them in daily practice, are outlined below.
- NICE is clear that you should not refer solely on IOP measurement using NCT, and where elevated pressure of 24mmHg or above is the only finding (normal disc and field, and open angles), then a Goldmann-type pressure should be measured prior to any HES referral. People with IOP below 24mmHg and no other signs of glaucoma should be advised to continue with their routine eye examinations
- You should not refer people who have been discharged from the HES after an assessment for COAG and related conditions unless clinical circumstances have changed, and a new referral is fully justified.
- Where you have a local community Glaucoma Referral Refinement service (GRR), and you do not participate in that service, your first step should be to refer your patients with raised IOP (>24 mm Hg) to an accredited practice, providing there are no other signs of glaucoma, pigment dispersion syndrome (PDS), pseudoexfoliation syndrome (PXS) or angle closure. This will enable refinement before referral for diagnosis of COAG or ocular hypertension (OHT). GRR has been commissioned by North Staffordshire and Stoke-on-Trent CCGs in the north of the county, and by Cannock Chase, SE Staffordshire & Seisdon Peninsula and Stafford & Surrounds CCGs in the south of the county. A full list of GRR participating practices can be found on the LOC website.
- If you are doing sight testing under GOS (without a referral refinement service in place – this applies to any patient registered with an East Staffordshire GP surgery, as East Staffordshire CCG is the only Staffordshire CCG not to have commissioned a GRR service): When you are concerned about a patient who is having a routine eye examination and you have discovered that there is:
1. Occludeable anterior chamber angles &/or pigment dispersion syndrome or
pseudoexfoliation syndrome, or
2. Glaucomatous optic nerve head damage, or
3. Visual field defect consistent with glaucoma, or
4. IOP is 24 mmHg or above (note that the threshold has changed from
Then, depending on clinical circumstances, you should refer the patient
to the HES for a diagnosis either routinely, urgently or as same day emergency
if signs & symptoms of angle closure are present.
- If your practice is contracted to deliver community eye care services and you are accredited to participate in either the North Staffordshire or the South Staffordshire Glaucoma Referral Refinement (GRR) service (or you work in a practice that belongs to one of the Staffordshire GRR services): The current service protocols still stand and will not affected by the new NICE Glaucoma guideline - at least not in the short term. Therefore, any patients who are found to have IOPs of 22mmHg or above during the sight test and no other Glaucoma relevant findings (open angles, no PDS, PXS, normal discs and field), please book them in for GRR Test A as normal – ideally on the same day as the sight test.
- NICE recommends, before referral for further investigation and diagnosis of COAG and related conditions, people should be offered all of the following tests:
1) central visual field assessment using standard automated perimetry (full threshold or suprathreshold)
2) optic nerve assessment and fundus examination using stereoscopic slit lamp biomicroscopy (with pupil dilatation if necessary), and OCT or optic nerve image if available
3) IOP measurement using Goldmann-type applanation tonometry
4) peripheral anterior chamber configuration and depth assessments using the Van Herick test, or using gonioscopy or OCT if available.
- Depending on your role, you should 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.
Thank you for your attention. If you are a practitioner not accredited to take part in GRR but you are interested in becoming involved, please contact Alison Lowell at the LOC office for further information – likewise, if anyone has any other questions relating to the new guideline.
Mark McCracken and Irfan Razvi