Update information

November 2017: This guideline is an update of NICE guideline CG85 (published April 2009) and replaces it.

New recommendations have been added for case-finding, diagnosis, reassessment and treatment.

These are marked as: [2017].

Recommendations that have been changed

Amended recommendation wording (change to meaning)

Recommendation in 2009 guideline

Recommendation in current guideline

Reason for change

Obtain an optic nerve head image at diagnosis for baseline documentation. (1.1.4)

Obtain an optic nerve head image at diagnosis for baseline documentation (for example, a stereoscopic optic nerve head image or OCT). (1.2.4)

Clarification added that this image may be acquired by a stereoscopic optic nerve head image (leaving it open to either biomicroscopy slit lamp examination or stereo photography) or OCT, whichever is more readily available at the time of diagnosis.

Offer standard automated perimetry (central thresholding test) to all people who have established COAG and those suspected of having visual field defects who are being investigated for possible COAG. People with diagnosed OHT and those suspected of having COAG whose visual fields have previously been documented by standard automated perimetry as being normal may be monitored using supra-threshold perimetry (see tables 4 and 5 for recommended monitoring intervals). (1.2.5)

When clinically indicated, repeat visual field testing using standard automated perimetry (central thresholding test) for people with COAG and those suspected of having visual field defects who are being investigated for possible COAG (see tables 2 and 3 for recommended reassessment intervals). (1.4.3)

The original recommendation contained 2 separate instructions (1 for people with established COAG and those having initial investigation for possible COAG, and 1 for follow-up of people with an established diagnosis of suspected COAG or OHT). These 2 instructions have now been separated into 2 recommendations to improve clarity.

Offer standard automated perimetry (central thresholding test) to all people who have established COAG and those suspected of having visual field defects who are being investigated for possible COAG. People with diagnosed OHT and those suspected of having COAG whose visual fields have previously been documented by standard automated perimetry as being normal may be monitored using supra-threshold perimetry (see tables 4 and 5 for recommended monitoring intervals). (1.2.5)

When clinically indicated, repeat visual field testing using either a central thresholding test or a supra-threshold test for people with OHT and those suspected of having COAG whose visual fields have previously been documented by standard automated perimetry as being normal (see tables 1 and 2 for recommended reassessment intervals). (1.4.4)

As above, the original recommendation contained 2 separate instructions (1 for people with established COAG and those having initial investigation for possible COAG, and 1 for follow-up of people with an established diagnosis of suspected COAG or OHT). These 2 instructions have now been separated into 2 recommendations to improve clarity.

The original recommendation was suggesting that for people with OHT and COAG suspects with normal visual fields, it would be acceptable to use the supra-threshold test as opposed to the superior central thresholding test (CTT) recommended for those with established COAG. However the committee wished to clarify that the CTT is also an option for this population if it is clinically available.

Offer alternative pharmacological treatment (a prostaglandin analogue, beta-blocker, carbonic anhydrase inhibitor or sympathomimetic) to treated people with OHT or suspected COAG whose IOP cannot be reduced sufficiently to prevent the risk of progression to sight loss. More than one agent may be needed concurrently to achieve target IOP. (1.3.5)

Offer a drug from another therapeutic class (beta-blocker, carbonic anhydrase inhibitor or sympathomimetic) to people with an IOP of 24 mmHg or more whose current treatment is not reducing IOP sufficiently to prevent the risk of progression to sight loss. Topical drugs from different therapeutic classes may be needed at the same time to control IOP. (1.5.6)

Clarification that the drug should be from another therapeutic class when switching to another monotherapy and when adding another drug. This clarification was considered important because committee members were aware of inappropriate switching through multiple examples of drugs from the same class (for example, multiple PGA switches).

Offer a preservative-free preparation to people with OHT or suspected COAG and an allergy to preservatives only if they are at high risk of conversion to COAG (IOP more than 25 and up to 32 mmHg and CCT less than 555 micrometres, or IOP more than 32 mmHg). (1.3.7)

Offer preservative-free eye drops to people who have an allergy to preservatives or people with clinically significant and symptomatic ocular surface disease, but only if they are at high risk of conversion to COAG. (1.5.8)

High risk of conversion is no longer defined in the guideline by IOP and CCT so these parameters have been removed from the recommendation. Treatment adherence may be significantly affected by both allergic and non-allergic reactions (preservative toxicity). Preservative toxicity is a particular problem for people with ocular surface diseases so this group was added to the recommendation.

Offer people with advanced COAG surgery with pharmacological augmentation (MMC or 5-FU) as indicated. Offer them information on the risks and benefits associated with surgery. (1.4.3)

Offer people with advanced COAG, surgery with pharmacological augmentation (MMC) as indicated. Offer them information on the risks and benefits associated with surgery. (1.5.13)

5FU is no longer used as standard practice during surgical treatment and postoperative care.

Offer people who present with advanced COAG and who are listed for surgery interim treatment with a prostaglandin analogue. (1.4.4)

Offer people who present with advanced COAG and who are listed for surgery, interim treatment with a PGA prescribed generically. (1.5.14)

Generic PGAs are now recommended in the guideline for first-line treatment.

Check the person's adherence to their treatment and eye drop instillation technique in people with COAG whose IOP has not been reduced sufficiently to prevent the risk of progression to sight loss despite pharmacological treatment. If adherence and eye drop instillation technique are satisfactory offer one of the following:

  • alternative pharmacological treatment (a prostaglandin analogue, beta-blocker, carbonic anhydrase inhibitor or sympathomimetic); more than one agent may be needed concurrently to achieve target IOP

  • laser trabeculoplasty

  • surgery with pharmacological augmentation (MMC or 5-FU) as indicated.

If the pharmacological treatment option is chosen, after trying two alternative pharmacological treatments consider offering surgery with pharmacological augmentation (MMC or 5-FU) as indicated or laser trabeculoplasty. (1.4.6)

Ask about adherence to treatment and check the eye drop instillation technique in people with COAG whose IOP has not been reduced sufficiently to prevent the risk of progression to sight loss despite pharmacological treatment. If adherence and eye drop instillation technique are satisfactory offer 1 of the following:

  • a drug from another therapeutic class (a beta-blocker, carbonic anhydrase inhibitor or sympathomimetic); topical drugs from different therapeutic classes may be needed at the same time to control IOP

  • laser trabeculoplasty

  • surgery with pharmacological augmentation (MMC) as indicated.

If the drug treatment option is chosen, after trying drugs from 2 therapeutic classes, consider offering surgery with pharmacological augmentation (MMC) as indicated or laser trabeculoplasty. (1.5.16)

Clarification that the drug should be from another therapeutic class when switching to another monotherapy and when adding another drug. 5FU is no longer used as standard practice during surgical treatment and postoperative care.

Offer surgery with pharmacological augmentation (MMC or 5-FU) as indicated to people with COAG who are at risk of progressing to sight loss despite treatment. Offer them information on the risks and benefits associated with surgery. (1.4.7)

Offer surgery with pharmacological augmentation (MMC) as indicated to people with COAG who are at risk of progressing to sight loss despite treatment. Offer them information on the risks and benefits associated with surgery. (1.5.17)

5FU is no longer used as standard practice during surgical treatment and postoperative care.

Consider offering people with COAG who are intolerant to a prescribed medication:

  • alternative pharmacological treatment (a prostaglandin analogue, beta-blocker, carbonic anhydrase inhibitor or sympathomimetic) or

  • a preservative-free preparation if there is evidence that the person is allergic to the preservative.

After trying two alternative pharmacological treatments consider offering surgery with pharmacological augmentation (MMC or 5‑FU) as indicated or laser trabeculoplasty. (1.4.8)

Consider offering people with COAG who cannot tolerate a treatment:

  • a drug from another therapeutic class (a beta-blocker, carbonic anhydrase inhibitor or sympathomimetic) or

  • preservative-free eye drops if there is evidence that the person is allergic to the preservative or has clinically significant and symptomatic ocular surface disease

After trying drugs from 2 therapeutic classes, consider offering surgery with pharmacological augmentation (MMC) as indicated or laser trabeculoplasty. (1.5.18)

Clarification that the drug should be from another therapeutic class when switching to another monotherapy. Treatment adherence may be significantly affected by both allergic and non-allergic reactions (preservative toxicity). Preservative toxicity is a particular problem for people with ocular surface diseases so this group was added to the recommendation.

5FU is no longer used as standard practice during surgical treatment and postoperative care.

After surgery offer people with COAG whose IOP has not been reduced sufficiently to prevent the risk of progression to sight loss one of the following:

  • pharmacological treatment (a prostaglandin analogue, beta‑blocker, carbonic anhydrase inhibitor or sympathomimetic); more than one agent may be needed concurrently to achieve target IOP

  • further surgery

  • laser trabeculoplasty or cyclodiode laser treatment. (1.4.9)

After surgery offer people with COAG whose IOP has not been reduced sufficiently to prevent the risk of progression to sight loss 1 of the following:

  • pharmacological treatment; topical drugs from different therapeutic classes may be needed at the same time to control IOP

  • further surgery

  • laser trabeculoplasty or cyclodiode laser treatment. (1.5.19)

Clarification that the drug should be from another therapeutic class when switching to another monotherapy and when adding another drug.

Offer people with COAG who prefer not to have surgery or who are not suitable for surgery:

  • pharmacological treatment (a prostaglandin analogue, beta‑blocker, carbonic anhydrase inhibitor or sympathomimetic); more than one agent may be needed concurrently to achieve target IOP

  • laser trabeculoplasty or cyclodiode laser treatment.

(1.4.10)

Offer people with COAG who prefer not to have surgery or for whom surgery is not suitable:

  • pharmacological treatment; topical drugs from different therapeutic classes may be needed at the same time to control IOP

  • laser trabeculoplasty or cyclodiode laser treatment. (1.5.20)

Clarification that the drug should be from another therapeutic class when switching to another monotherapy and when adding another drug.

Offer people the opportunity to discuss their diagnosis, prognosis and treatment, and provide them with relevant information in an accessible format at initial and subsequent visits. This may include information on the following:

  • their specific condition (OHT, suspected COAG and COAG), its life-long implications and their prognosis for retention of sight

  • that COAG in the early stages and OHT and suspected COAG are symptomless

  • that most people treated for COAG will not go blind

  • that once lost, sight cannot be recovered

  • that glaucoma can run in families and that family members may wish to be tested for the disease

  • the importance of the person's role in their own treatment – for example, the ongoing regular application of eye drops to preserve sight

  • the different types of treatment options, including mode of action, frequency and severity of side effects, and risks and benefits of treatment, so that people are able to be active in the decision-making process

  • how to apply eye drops, including technique (punctal occlusion and devices) and hygiene (storage)

  • the need for regular monitoring as specified by the healthcare professional

  • methods of investigation during assessment

  • how long each appointment is likely to take and whether the person will need any help to attend (for example, driving soon after pupil dilatation would be inadvisable)

  • support groups

  • compliance aids (such as dispensers) available from their GP or community pharmacist

  • Letter of Vision Impairment (LVI), Referral of Vision Impairment (RVI) and Certificate of Vision Impairment (CVI) registration

  • Driver and Vehicle Licensing Agency (DVLA) regulations. (1.6.1)

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. This may include information on the following:

  • their specific condition (OHT, suspected COAG and COAG), its life-long implications and their prognosis for retention of sight

  • that COAG in the early stages and OHT and suspected COAG are symptomless

  • that most people having treatment for COAG will have good quality of life and not go blind

  • that once lost, sight cannot be recovered

  • that glaucoma can run in families and that family members may wish to be tested for the condition

  • the importance of the person's role in their own treatment – for example, the ongoing regular application of eye drops to preserve sight

  • the different types of treatment options, including mode of action, frequency and severity of side effects, and risks and benefits of treatment, so that people are able to take an active part in decision-making

  • how to apply eye drops, including technique (punctal occlusion and devices) and hygiene (storage)

  • the need for regular monitoring as specified by the healthcare professional

  • methods of investigation during assessment

  • how long each appointment is likely to take and whether the person will need any help to attend (for example, driving soon after pupil dilatation would be inadvisable)

  • the eye clinic liaison officer (ECLO)

  • support organisations and support groups

  • compliance aids (such as dispensers) available from their GP or community pharmacist

  • Letter of Vision Impairment (LVI), Referral of Vision Impairment (RVI) and Certificate of Vision Impairment (CVI), registration

  • Driver and Vehicle Licensing Agency (DVLA) regulations. (1.7.1)

Amended to indicate that people should have the opportunity to discuss referral, and discharge, and that patient information should also include:

  • reassurance that most people having treatment for COAG will have a good quality of life

  • reference to the eye clinic liaison officer (ECLO) as these now available in many clinics

  • reference to support organisations.

ISBN: 978-1-4731-2713-5

  • National Institute for Health and Care Excellence (NICE)