Excerpt

The scope of this NICE guideline on diagnosing and managing chronic open-angle glaucoma has been extended to cover referral. This includes the most effective service models for referral-filtering schemes (repeat measures, enhanced case finding and referral refinement), the tests to be used for finding people with chronic open-angle glaucoma (COAG), suspected chronic open-angle glaucoma and ocular hypertension (OHT), and thresholds for onward referral. We have also updated the guidance on tests for diagnosis and reassessment, pharmacological treatments for lowering intraocular pressure and preserving visual field and reassessment intervals, which depend on prognosis.

The update has provided an opportunity to re-evaluate the clinical effectiveness, cost effectiveness and indications for treating OHT. Knowledge of corneal thickness is no longer needed to decide whether or not to treat OHT, and a single threshold of 24 mmHg is now recommended for both onward referral and treatment. Changes in the costs of pharmacological treatments, acknowledgement of short- and long-term variations in intraocular pressure and the uneven relationship between rising pressure and increased risk have allowed a simplification of the indications for OHT treatment.

Control of intraocular pressure remains critical to the therapeutic approach, with intensity of treatment and ongoing management being guided by disease severity and progression as shown by visual field change, morphological change in the optic disc, and the likelihood of progressive sight loss. Reassessment at each visit is emphasised, encouraging flexible clinical judgement about the frequency of visits and options for treatment, including stopping treatment when the perceived risk to a sighted lifetime is low.

Where fresh evidence was not found the guideline has not been updated, that is, accuracy of visual field tests, surgical interventions, laser procedures and information, education and support needed to achieve adherence to treatment.

Updating significant elements of the guideline has required an intensive effort from both the professional members of the National Guideline Centre and the guideline committee, who are thanked for their expertise, thoughtful work and in-depth discussions at and between guideline committee meetings.

Contents

• Guideline Committee members [2009]
• Guideline Committee members [2017]
• NGC technical team members [2017]
• Acknowledgements
• 1. Guideline summary
  • 1.1. Algorithms
  • 1.2. Full list of recommendations
  • 1.3. Key research recommendations
  • 1.4. How this guideline was updated
• 2. Introduction
  • 2017 Update
  • CG85 Introduction
• 3. Development of the guideline
  • 3.1. What is a NICE guideline?
  • 3.2. Remit
  • 3.3. Who developed this guideline?
• 4. Methods
  • 4.1. Developing the review questions and outcomes
  • 4.2. Searching for evidence
  • 4.3. Identifying and analysing evidence of effectiveness
  • 4.4. Identifying and analysing evidence of cost-effectiveness
  • 4.5. Developing recommendations
• 5. Prognostic risk tools
  • 5.1. Increased risk of conversion to chronic open-angle glaucoma (COAG)
  • 5.2. Increased risk of COAG progression
• 6. Tests used in case finding, diagnosis and reassessment
  • 6.1. Introduction
  • 6.2. Visual field evidence
  • 6.3. Accuracy of structural tests for identifying glaucoma damage and monitoring the progression of glaucoma damage (damage of optic nerve head, macula and retinal nerve fibre layer)
  • 6.4. Accuracy of intraocular pressure (IOP) tests
  • 6.5. Accuracy of tests for identifying closed or occludable anterior chamber angle
  • 6.6. Central corneal thickness measurement evidence
  • 6.7. Recommendation and link to evidence
• 7. Reassessment intervals
  • 7.1. Optimum intervals for ocular hypertension, suspected chronic open-angle glaucoma or both
  • 7.2. Optimum intervals for chronic open-angle glaucoma
• 8. Overview of treatment
  • 8.1. Introduction
  • 8.2. Any treatment vs. no treatment
  • 8.3. Conclusions
• 9. Treatment of ocular hypertension, suspected chronic open-angle glaucoma and confirmed chronic open-angle glaucoma
  • 9.1. Pharmacological treatment for ocular hypertension, suspected chronic open-angle glaucoma and confirmed chronic open-angle glaucoma
  • 9.2. Laser treatment for COAG
  • 9.3. Surgical Treatment for COAG
  • 9.4. Patients with COAG or OHT associated with pseudoexfoliation or pigment dispersion
  • 9.5. Recommendations and link to evidence
• 10. Complementary and alternative interventions
  • 10.1. Introduction
  • 10.2. Complementary and alternative treatments
  • 10.3. Conclusions
• 11. Organisation of care
  • 11.1. Service models for case finding, referral filtering and diagnosis
  • 11.2. Skills required by healthcare professionals
  • 11.3. Effectiveness of monitoring by different healthcare professionals
  • 11.4. Effectiveness of treatment by different healthcare professionals
• 12. Provision of information for patients
  • 12.1. Introduction
• 13. Reference list
• 14. Acronyms and abbreviations
• 15. Glossary
• Appendices
  • Appendix A. Scope
  • Appendix B. Declarations of interest
  • Appendix C. Clinical review protocols
  • Appendix D. Health economic review protocol
  • Appendix E. Clinical study selection
  • Appendix F. Health economic study selection
  • Appendix G. Literature search strategies
  • Appendix H. Clinical evidence tables
  • Appendix I. Health economic evidence tables
  • Appendix J. GRADE tables
  • Appendix K. Forest plots and coupled sensitivity and specificity plots
  • Appendix L. Excluded clinical studies
  • Appendix M. Excluded health economic studies
  • Appendix N. Cost-effectiveness analysis: treatment for ocular hypertension
  • Appendix O. Network meta-analysis: the effectiveness of beta-blockers and prostaglandin analogues in lowering intraocular pressure
  • Appendix P. CG85 Cost-effective analysis
  • Appendix Q. Research recommendations
  • Appendix R. Updates to CG85
  • Appendix S. NICE technical team
  • Appendix T. References
  • Appendix U. Glaucoma: diagnosis and management of chronic open angle glaucoma and ocular hypertension

Final

Commissioned by the National Institute for Health and Care Excellence

Disclaimer: Healthcare professionals are expected to take NICE guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and, where appropriate, their guardian or carer.

Partial update 2017

This is a partial update of the 2009 clinical guideline on Glaucoma: diagnosis and management of chronic open-angle glaucoma and ocular hypertension.

The sections new or updated in 2017 are:

• Guideline committee and scope
• Methodology
• Case finding, diagnosis and monitoring
• Service models
• Prognostic risk tools
• Treatment of ocular hypertension, suspected chronic open-angle glaucoma and chronic openangle glaucoma

All other sections and recommendations for the 2009 guideline remain unchanged.

The content of other sections has not been amended, and we have integrated these new sections into the relevant chapters of the old publication. This has inevitably led to inconsistencies in style of write up for reviews.

Unamended sections of the guideline are highlighted in a pale orange box and have a ‘2009’ bar in the right hand margin.

To view the 2009 guideline in its entirety, please see appendix U.

The National Guideline Centre, formally the National Clinical Guideline Centre, was formed in April 2009 following the merger of the National Collaborating Centres for Acute Care, Chronic Conditions, Nursing and Supportive Care and Primary Care.