Glaucoma Quality Standard

1. People are referred to a consultant ophthalmologist for further assessment and definitive diagnosis if the optometrist or other healthcare professional suspects COAG. There are local agreements in place for referral refinement.

2. People with elevated IOP 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.

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

4. 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.

5. 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.

6. 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.

7. People with COAG, suspected COAG or with OHT have a regular review of management options with their healthcare professional, taking into account comorbidity and other changed circumstances, including a discussion of the benefits and risks of stopping treatment for those at low risk of progressing to visual impairment.

8. 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.

9. 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.

10. People with COAG who are progressing to loss of vision despite treatment or who present with advanced visual loss are offered surgery with pharmacological augmentation (for example, MMC or 5FU) as indicated and information on the risks and benefits associated with surgery.

11. People with COAG, suspected COAG or with OHT are given the opportunity to discuss their diagnosis, prognosis and management, and are provided with relevant and accessible information and advice at initial and subsequent visits in accordance with NICE guidance.

12. People with 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.

This NICE quality standard defines clinical best practice within this topic area. It provides specific, concise quality statements, measures and audience descriptors to provide patients and the public, health and social care professionals, commissioners and service providers with definitions of high-quality care.

Rationale for developing this quality standard

Chronic open angle glaucoma (COAG) is a common and potentially blinding condition. It is usually asymptomatic until advanced and many people will be unaware there is a problem with their eyes until severe visual damage has occurred. Ocular hypertension (OHT) is a major risk factor for developing COAG, although COAG can occur with or without raised eye pressure. Approximately 10% of UK blindness registrations are attributed to glaucoma and it accounts for over one million hospital eye service visits each year. Once diagnosed people with COAG need lifelong monitoring so that any progression of visual damage can be detected. Once lost, sight cannot be restored, and controlling the condition together with prevention, or at least minimisation of ongoing damage, is crucial to maintaining a sighted lifetime. This quality standard describes markers of high-quality, cost-effective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience of care for adults with chronic open angle glaucoma.

Scope of the quality standard

Care for people with COAG, suspected COAG or with OHT.

Glaucoma quality statements

The quality standard for glaucoma requires that services should be commissioned from and coordinated across all relevant agencies encompassing the whole glaucoma care pathway, including primary, secondary and social care. An integrated approach to provision of services is fundamental to the delivery of high quality care to people with glaucoma. A local register of glaucoma-related conditions organised according to diagnosis (for example, chronic open angle glaucoma (COAG), suspected COAG, ocular hypertension (OHT), angle closure, secondary glaucoma) and sight impairment could be used to facilitate such integration.

Download the Glaucoma areas of care map to see the quality statements mapped against the areas of glaucoma care. Download a large print version of the quality statements mapped against the areas of glaucoma care.

Policy context

Department of Health (2010) The NHS Outcomes Framework 2011/12. Available from www.dh.gov.uk
Department of Health (2009) Primary Care and Community Services: Improving Eye Health Services. Available from www.dh.gov.uk
Department of Health (2007) Commissioning Toolkit for community based eye care services. Available from www.dh.gov.uk
Royal National Institute of Blind People (2008) UK Vision Strategy: Setting the direction for eye health and sight loss services. Available from www.vision2020uk.org.uk
Department of Health (2004) National Eye Care Services Steering Group - First report.Available from www.dh.gov.uk
Department of Health (2001) National service framework for older people. Available from www.dh.gov.uk

Key development sources

Glaucoma: diagnosis and management of chronic open angle glaucoma and ocular hypertension. NICE clinical guideline 85 (2009: NHS Evidence accredited source). Available from www.nice.org.uk

The College of Optometrists and The Royal College of Ophthalmologists (2009) Guidance on the referral of glaucoma suspects by community optometrists. Available from www.college-optometrists.organd www.rcophth.ac.uk

National Patient Safety Agency (2009) Rapid Response Report. Preventing delay to follow up for patients with glaucoma. Available from www.nrls.npsa.nhs.uk

Development team

Director	Fergus Macbeth
Associate Director	Nicola Bent
Consultant Clinical Adviser	Tim Stokes
Lead Analyst	Denise Dutton

Topic Expert Group: Glaucoma

Consultation feedback

Consultation of the glaucoma quality standard took place from 4 November to 16 December 2010. In total, 113 stakeholders were contacted during consultation. All eligible comments were reviewed by the Topic Expert Group and the standard was updated accordingly.

Implementation support materials

Publication partners

Many organisations share NICE's commitment to improve quality by making it clear what quality care is for patients and the public, health and social care professionals, commissioners and service providers.

So that these standards reach the widest possible audience, some of the organisations who have been involved in the development process, and who endorse the glaucoma quality standard, have become partners in its publication.

These organisations are:

Association of Optometrists
The College of Optometrists
International Glaucoma Association
Royal College of Nursing - ophthalmic forum
Royal National Institute for Blind People
Royal Pharmaceutical Society
The Royal College of Ophthalmologists
UK and Eire Glaucoma Association