Suspect glaucoma and ocular hypertension (NICE and SIGN)

Key Points
  • Referral should only be considered after visual fields assessment, stereoscopic viewing of the optic disc, Goldmann applanation tonometry, and anterior chamber and angle assessment.
  • Referral should not be undertaken solely on non-contact tonometry.
  • Repeat measurements of field defects and IOP of ≥24mmHg or asymmetry of >4mmHg merit referral, as does structural change at the disc.
  • Opportunistic case-finding results in too many false positive referrals.
  • Referral filtering services include repeat measures by community optometrists, enhanced case finding schemes with more detailed re-assessment by accredited optometrists or true referral refinement scheme (which includes gonioscopy and requires a higher qualification).
  • SIGN (Scottish Intercollegiate Guidelines Network) guidelines in Scotland include repeat measurements (including pachymetry and Goldmann applanation tonometry).
  • NICE guidance on suspect and glaucoma applies to England. The original guidance was for management and assessment, and resulted in over-referral of patients. Revised guidance from NICE includes reference to referral from community practice.
  • SIGN recommends disc assessment including disc height measurement.
  • Glaucoma patients with stability might be discharged for community optometry monitoring.
  • Spaeth grading of disc damage helps identify and grade disc changes with glaucomatous disease.
  • SIGN has moved away from the ISNT ‘rule’ – better to look at the whole neuroretinal rim for thinning rather than just quadrant assessment.