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Consultant Ophthalmologist,
Cataract & Refractive Surgeon

BMedSci BM BS MRCS MRCSEd MRCOpth FRCOphth MMedLaw PgD Cataract & Refractive Surgery

NICE Glaucoma Guidance

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You are all aware that NICE have issued guidance with regards the management of glaucoma. All in all this is a positive step. It will standardise and enhance the care for glaucoma patients across the country.

There have been several issues which have been raised by the Association of Optometrists regarding the guidance.

The main issue is regarding when to refer patients in for assessment. Previously optometrists have been excellent at following patients up with marginally high pressures and only referring them if the pressure becomes excessively raised or they had other features of suspect glaucoma. Now the guidance recommends that patients with a pressure above 21mmHg are referred to the hospital as these patients are classed as an ocular hypertensive. This is naturally causing a significant increase in the number of referrals into the hospital.

The Association of Optometrists has stated that if you do not refer patients in then you are at risk as your indemnity will not cover you. I can fully understand the reasons behind the recommendations and understand if you feel you have no choice but to send patients in.

In the end we have to consider what is best for the patient and it is quite clear that patients with a one-off IOP reading of 22 or 23mmHg on air-puff tonometry with healthy optic discs and a normal visual field are extremely unlikely to come to harm if they are simply followed up again by you (essentially what you have been doing for many years). The key point is that we know that air-puff IOP measurement tends to overestimate the true IOP and this is the likely reason for these high readings. If you are able to measure Goldmann Applanation Tonometry pressures then I think you should adhere strictly to the NICE guidance and refer patients with an IOP above 21mmHg to the hospital.

In the end it is important that you do what is comfortable for you as an independent practitioner.

The advice from the Association specifically tells you to ignore attempts from your local Ophthalmologists to change your practice but it is worth a try!