Services for people at risk of developing glaucoma

NICE commissioning guides [CMG44] Published date:

4 Specifying services for people at risk of developing glaucoma

This guide focuses on the following areas of care for people at risk of developing glaucoma:

Service models for services for people at risk of developing glaucoma are provided in section 4.4.

4.1 Referral and assessment

The NICE quality standard on glaucoma states that:

'People are referred to a consultant ophthalmologist for further assessment and definitive diagnosis if the optometrist or other healthcare professional suspects COAG (chronic open angle glaucoma). There are local agreements in place for referral refinement.' (Quality statement 1)

'People with elevated IOP (intraocular pressure) alone are referred to an appropriately qualified healthcare professional for further assessment on the basis of perceived risk of progression to COAG. There are agreements in place for repeat measures.' (Quality statement 2)

A number of primary healthcare professionals, most commonly optometrists but also GPs with a special interest in ophthalmology, will routinely encounter people with ocular hypertension (OHT) or suspected COAG.

Commissioners should ensure that they commission services that enable people with raised IOP, visual field defects and/or suspicious optic nerve head appearance consistent with COAG to be appropriately assessed in the community before referral to a consultant ophthalmologist in a timely manner if COAG is suspected.

4.1.1 Repeat measures of IOP

A key element in the diagnosis of OHT, suspected COAG and COAG is the measurement of IOP. For the purposes of diagnosis and monitoring, NICE recommends that IOP is measured using Goldmann applanation tonometry (slit lamp mounted) (see NICE clinical guideline 85 on glaucoma, recommendation 1.1.1).

Commissioners should be aware that most community optometrists use non-contact (air puff) tonometers or rebound tonometers to measure IOP during routine eye examinations[8]. These are considered to be less accurate than Goldmann style applanation tonometers. Therefore, when commissioning optometry services, commissioners should specify that people with an initial IOP reading of greater than 21 mmHg but no other signs of glaucoma have their measures repeated before referral to the Hospital Eye Service. Commissioners should specify that:

Commissioners should work with providers to agree how far apart initial and repeat measurements should be taken, and specify this. First and second repeat measures should be at least a few days apart.

Commissioners should take note of studies which demonstrate that the number of people referred to the Hospital Eye Service for OHT is reduced when using Goldmann applanation tonometry rather than non-contact tonometers[9].

Commissioners should agree a fee for repeat measures which covers the time taken to conduct them, and consider the costs associated with the purchase, maintenance or replacement of equipment when this is required.

Taking measures of IOP using Goldmann applanation tonometers is a core competence of optometrists. However, commissioners may need to work with local providers to satisfy themselves that refresher training is available to practitioners who require or request it.

4.1.2 Referral refinement

Commissioners should discuss with local partners, particularly community optometrists and the Hospital Eye Service, the possibility of commissioning a referral refinement service if one is not already in place. Referral refinement goes further than a repeat measures service, and involves further tests, such as central corneal thickness (CCT) measurements and further examination of the optic nerve head, and the interpretation of the clinical findings to determine if glaucoma is present.

Commissioners should be aware that these skills and the equipment required are not widely available in community optometry. The topic advisory group estimate that only a minority of optometrists have the qualifications and competence necessary to diagnose OHT and suspected COAG, and most of these will work in the Hospital Eye Service or other consultant-led community-based ophthalmology services. Therefore in some cases it will be appropriate for people to be referred directly to the Hospital Eye Service or community-based ophthalmology services after repeat measures (see section 4.1.1) or if they have suspected COAG (see section 4.2).

Commissioners should explore the availability of community optometrists who can provide referral refinement in line with NICE guidance and quality standards. They should be willing and qualified providers with demonstrable training, competence and experience of testing people for OHT and COAG and the interpretation of these clinical findings. Commissioners should also estimate the demand for this training among local community optometrists when planning the service.

Commissioners should also explore the availability of other qualified and willing providers who might be able to provide referral refinement, such as community-based ophthalmology services.

4.1.3 Referral for diagnosis of OHT, suspected COAG or COAG

Commissioners should ensure that all services they commission for the assessment of OHT and suspected COAG enable:

  • 'red-flagged' cases to be referred directly and urgently to the Hospital Eye Service. Red-flagged cases will include people with suspected acute angle-closure glaucoma or people with a very high IOP (the measure of 'high IOP' is to be locally determined with key partners, but is likely to be over 30 mmHg)

  • the healthcare professional to make direct referrals to a consultant ophthalmologist on the basis of test results.

Commissioners should ask providers to demonstrate that systems are in place to enable healthcare professionals who refer people with OHT, suspected COAG and COAG to indicate the relative urgency of all referrals, to help manage demand in the Hospital Eye Service.

4.2 Diagnosis

The NICE quality standard on glaucoma states that:

'People referred for definitive diagnosis in the context of possible COAG or with OHT receive all relevant tests in accordance with NICE guidance.' (Quality statement 3)

'People with COAG, suspected COAG or with OHT are diagnosed and have a management plan formulated by a suitably trained healthcare professional with competencies and experience in accordance with NICE guidance.' (Quality statement 4)

Services for the definitive diagnosis and development of a management plan for people with OHT or suspected COAG are typically provided in the Hospital Eye Service or a community ophthalmology service by ophthalmologists, or by nurse specialists, optometrists and orthoptists working under the supervision of a consultant ophthalmologist.

Training is required to diagnose OHT or suspected COAG, and to develop a management plan. This role may be performed by suitably trained community-based optometrists, although it is estimated that currently less than 0.49% of optometrists have the relevant qualifications and experience[10].

For all services, commissioners should:

  • specify that people referred for definitive diagnosis of COAG receive all relevant tests in accordance with the definitions in quality statement 3

  • consider how best to integrate the process of definitive diagnosis of COAG or OHT with that of referral refinement discussed in section 4.2

  • satisfy themselves that all people with existing confirmed diagnoses of OHT and suspected COAG have management plans formulated by suitably trained healthcare professionals.

4.3 Timely monitoring, management and discharge

4.3.1 Monitoring

The NICE quality standard on glaucoma states:

'People diagnosed with COAG, suspected COAG or with OHT are monitored at intervals according to their risk of progressive loss of vision in accordance with NICE guidance.' (Quality statement 5)

'People diagnosed with COAG, suspected COAG or with OHT have access to timely follow-up appointments and specialist investigations at intervals in accordance with NICE guidance. Sufficient capacity is put in place to provide this service, and systems are developed to identify people needing clinical priority if appointments are cancelled, delayed or missed.' (Quality statement 8)

Services for the monitoring and management of people with OHT or suspected COAG can be commissioned from a range of providers, including:

  • the Hospital Eye Service

  • community-based ophthalmology services

  • community-based optometrists

  • general practice (typically GPs with a special interest in eye care or as part of a shared care agreement with optometry).

When commissioning services for the monitoring of people with OHT and suspected glaucoma, commissioners should:

  • ensure that every person with OHT and suspected COAG being monitored by providers has a management plan formulated by a suitably trained healthcare professional (see section 4.2)

  • specify that all providers follow the monitoring intervals for people with OHT and suspected COAG outlined in NICE clinical guideline 85 on glaucoma (see recommendations 1.2.10 and 1.2.11)

  • set referral to assessment times, and referral to diagnosis times, and monitor these

  • ensure that providers have clear pathways for referring people with a change in clinical status to a suitably trained healthcare professional for assessment and diagnosis (see section 4.2).

Because of the risk of avoidable sight loss when people miss monitoring appointments, or when appointments are cancelled, commissioners should ensure they closely monitor providers' performance against the monitoring criteria in NICE guidance. Commissioners should follow the recommendations in the 'Rapid response report' from the National Patient Safety Agency (NPSA), which asks NHS organisations to review their systems and processes to minimise the risk of avoidable sight loss for people with suspected glaucoma, following reports of loss or deterioration of vision because of delayed, postponed or cancelled follow-up appointments (see box 2).

Box 2 Rapid response report – immediate actions for glaucoma services

Local organisations should:

  • Make NICE guidelines on glaucoma available to all relevant staff and develop an action plan to implement the recommendations.

  • Review levels of hospital-initiated cancellation of appointments for patients with established or suspected glaucoma through clinical governance forums.

  • Review patient 'did not attend' rates in order to identify and audit high-risk non-attending patients.

  • Identify the number of patients currently awaiting follow-up and confirm there is sufficient capacity within the local health community to meet this number in terms of outpatient appointments and any specialist investigations, for example visual field and optic disc imaging.

  • Develop a system whereby patients can be 'flagged' on the booking/appointment system to indicate the clinical priority given to the appointment and monitor activity to ensure compliance with NICE follow-up intervals.

  • Make information on glaucoma available to patients and ensure that there is a straightforward process for patients to reschedule appointments where necessary.

Commissioners should also ensure they are meeting the Department of Health's policy for patients who require appointments for assessment, review and/or treatment - use of planned (pending or review) lists.

4.3.2 Management

The NICE quality standard on glaucoma states:

'People with suspected COAG or with OHT are managed based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age, in accordance with NICE guidance.' (Quality statement 6)

Commissioners should specify that providers follow NICE guidance for the management of people with OHT and suspected COAG. Recommendation 1.3.1 in NICE clinical guideline 85 on glaucoma states:

'Offer people with OHT or suspected COAG with high IOP treatment based on estimated risk of conversion to COAG using IOP, CCT and age (see table 1 [table 6 in the guidance])'.

Table 1 Treatment for people with OHT or suspected COAG

CCT

More than 590 micrometres

555–590 micrometres

Less than 555 micrometres

Any

Untreated IOP (mmHg)

> 21 to 25

> 25 to 32

> 21 to 25

> 25 to 32

> 21 to 25

> 25 to 32

> 32

Age (years)[a]

Any

Any

Any

Treat until 60

Treat until 65

Treat until 80

Any

Treatment

No treatment

No treatment

No treatment

BB

PGA[b]

PGA

PGA

[a] Treatment should not be routinely offered to people over the age threshold unless there are likely to be benefits from the treatment over an appropriate timescale. Once a person being treated for OHT reaches the age for stopping treatment but has not developed COAG, healthcare professionals should discuss the option of stopping treatment.

The use of age thresholds is considered appropriate only where vision is currently normal (OHT with or without suspicion of COAG) and the treatment is purely preventative. Under such circumstances the threat to a person's sighted lifetime is considered negligible. In the event of COAG developing in such a person then treatment is recommended.

[b] If beta-blockers (BB) are contraindicated offer a prostaglandin analogue (PGA).

Commissioners should note recommendation 1.5.6 of NICE clinical guideline 85 on glaucoma which states that:

'People with a confirmed diagnosis of OHT or suspected COAG and who have an established management plan may be monitored (but not treated) by a suitably trained healthcare professional with knowledge of OHT and COAG, relevant experience and the ability to detect a change in clinical status. The healthcare professional should be able to perform and interpret all of the following:

  • Goldmann applanation tonometry (slit lamp mounted)

  • standard automated perimetry (central thresholding test)

  • central supra-threshold perimetry (this visual field strategy may be used to monitor people with OHT or COAG suspect status when they have normal visual field)

  • stereoscopic slit lamp biomicroscopic examination of the anterior segment

  • Van Henrick's peripheral anterior chamber depth assessment

  • examination of the posterior segment using slit lamp binocular indirect ophthalmoscopy.'

The topic advisory group confirmed that community-based optometrists can be commissioned to monitor all patients with OHT or suspected COAG, including those being prescribed medication, provided they have had a management plan formulated by a suitably trained healthcare professional (see section 4.2 on diagnosis) and the patient is being monitored within the boundaries of this management plan.

Commissioners should ensure that:

  • providers who monitor patients with OHT or suspected COAG are qualified and competent to perform all of the tests outlined in NICE guidance

  • protocols are in place to refer people with a change in clinical status, or who are not responding to treatment in accordance with the management plan, back to a suitably trained healthcare professional for a review of their management plan.

4.3.3 Discharge

The NICE quality standard on glaucoma states:

'People with COAG, suspected COAG or with OHT who are not recommended for treatment and whose condition is considered stable are discharged from formal monitoring with a patient-held management plan.' (Quality statement 12).

Commissioners should ensure that their pathways for people with OHT and suspected COAG include processes for discharge with a patient-held management plan, in accordance with recommendation 1.2.11 of NICE clinical guideline 85 on glaucoma:

'Discuss the benefits and risks of stopping treatment with people with OHT or suspected COAG who have both:

  • a low risk of ever developing visual impairment within their lifetime

  • an acceptable IOP.

If a person decides to stop treatment following discussion of the perceived risks of future conversion to COAG and sight loss, offer to assess their IOP in 1 to 4 months' time with further monitoring if considered clinically necessary.'

In accordance with NICE guidance, commissioners should specify that people with OHT who are monitored for 3–5 years but have no change in their clinical status and whose OHT is deemed stable should be discharged to community optometry for routine annual eye examinations.

4.3.4 Documentation

The NICE quality standard on glaucoma states:

'Healthcare professionals involved in the care of a person with COAG, suspected COAG or with OHT have appropriate documentation and records available at each clinical encounter in accordance with NICE guidance.' (Quality statement 9)

Commissioners need to ensure that patient information is available to all healthcare professionals involved in a person's care, whether or not this care is provided in a community setting or in the Hospital Eye Service. The topic-specific advisory group suggests that commissioners and providers consider innovative approaches to the transfer of patient information (in accordance with local information governance arrangements), for example:

  • referral and management forms that are used by all providers in the pathway

  • secure systems for transferring patient records, such as using the nhs.net email service or secure role-specific entry via a virtual private network (VPN) into a hospital-based electronic patient record system

  • patient-held management plans.

4.4 Service models

Commissioners may wish to consider commissioning services for people at risk of developing glaucoma in several different ways, and mixed models of provision may be appropriate across a local health economy. Commissioners may wish to consider shifting the focus of investment from secondary care services to community or primary care.

Commissioners may wish to work with their local QIPP lead to develop service models for people at risk of developing glaucoma. Example QIPP service models are provided below.

Table 2 Delivering QIPP through service models for people at risk of developing glaucoma

QIPP model

Example output

Glaucoma repeat measurement scheme

Reduce the number of unnecessary suspected glaucoma referrals to the Hospital Eye Service, thereby improving accuracy of referrals, generating savings and releasing capacity.

Glaucoma referral refinement

Reduce false positive referrals to secondary care; ensure patients are seen at the right time and place; reduce ophthalmology new glaucoma outpatient activity by 25%.

The Commissioning for Quality and Innovation (CQUIN) payment framework enables commissioners to reward excellence, by linking a proportion of English healthcare providers' income to the achievement of local quality improvement goals. Commissioners should work with clinicians when using the CQUIN payment framework as a lever for service change.

As outlined in the National Patient Safety Agency's 'Rapid response report NPSA/2009/RRR004: supporting information', commissioners may wish to set CQUIN performance measures relating to referral to assessment, assessment to treatment times and monitoring criteria.

Case studies

Commissioners may wish to refer to examples of service models for people at risk of developing glaucoma:

  • Commissioning models for referral refinement, monitoring and diagnosis are provided in The Local Optical Committee (LOC) Support Unit's 'Glaucoma referral refinement and OHT enhanced service pathways following NICE guidance – glaucoma referral refinement, ocular hypertension monitoring and ocular hypertension diagnosis'.

  • NHS Heywood, Middleton and Rochdale has commissioned a repeat measures service and a community glaucoma management service. The services have reduced outpatient attendances for glaucoma, reduced referral to treatment times and deliver care closer to home.

    • The repeat measures service is for optometry to provide two repeat measures using Goldmann applanation or Perkins tonometry, for people with an IOP greater than 21 mmHg as measured during a routine eye examination but with no other clinical signs of glaucoma. The service enables urgent referral (within 48 hours) to the glaucoma management service for people with an IOP greater than 32 mmHg. Fees are paid to participating optometrists for each repeat measure.

    • The glaucoma management service enables patients with diagnosed OHT, suspected COAG or COAG to be monitored in one of three community venues by an appropriately trained healthcare professional, typically an ophthalmologist or nurse specialist. The fees for the glaucoma management service are less than for a Hospital Eye Service outpatient appointment, thereby offering significant savings. Referral to treatment times are fast: 85% of patients are seen within 2 weeks of referral and 100% within 4 weeks. The service has very high reported patient satisfaction, with 79% rating the service as excellent and none as satisfactory or poor.

  • Commissioners should consider using incentives such as Locally Enhanced Service (LES) contracts to encourage the uptake of services for repeat measures or referral refinement among willing and qualified local providers.

  • Examples developed as part of the Department of Health's ongoing programme of support for community eye care services are available from 'Community eye care services: review of local schemes for low vision, glaucoma and acute care'.

(Please note – these examples are offered to share good practice and NICE makes no judgement on the compliance of this service with its guidance).



[8] Vernon SA, Hillman JH, MacNab HK et al. (2011) Community optometrist referral of those aged 65 and over for raised IOP post-NICE: AOP guidance versus joint college guidance – an epidemiological model. British Journal of Ophthalmology 95: 1534–6.

[9] Vernon SA, Hillman JH, MacNab HK et al. (2011) Community optometrist referral of those aged 65 and over for raised IOP post-NICE: AOP guidance versus joint college guidance – an epidemiological model. British Journal of Ophthalmology 95: 1534–6; Sheehan W, Adams D, Wells C et al. (2011) Does Goldmann applanation tonometry performed by community optometrists reduce referrals? A pilot study. British Journal of Ophthalmology 95: 295.

[10] The College of Optometrists Glaucoma Certificate A, or other equivalent qualification, are relevant qualifications for diagnosing OHT and suspected COAG. Prescribing competences would also be required where treatment is appropriate. If the optometrist does not have prescribing competences they can collaborate with a GP with a special interest in ophthalmology or an ophthalmologist.

NICE has accredited the process used by NICE to produce guides for commissioners. Accreditation is valid for 5 years from November 2011 and applies to guides produced since November 2008 using the processes described in 'Process manual for developing guides from NICE for commissioners: Information for internal NICE teams' (2011). More information on accreditation can be viewed at www.nice.org.uk/accreditation
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