Clinical Guidance and Monitoring for Change. Cecilia Fenerty MD FRCOphth Manchester Royal Eye Hospital

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1 Clinical Guidance and Monitoring for Change Cecilia Fenerty MD FRCOphth Manchester Royal Eye Hospital

2 Glaucoma Referral Criteria 2000 Original referral scheme Simple criteria based on IOP/Disc/Field Solitary and combined thresholds defined 2009/10 - NICE guidance and Joint College Guidance led to modifications Addition of age and CCT criteria to referral thresholds 2 years + for Manchester scheme to adopt new criteria after discussion with commissioners

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4 Treatment Algorithm OHT

5 Joint College Guidance Non-referral in specific scenarios 12. Practitioners may consider not referring patients at low risk of significant visual field loss in their lifetime - a. Patients aged 80 years and over with measured IOPs <26mmHg with otherwise normal ocular examinations (normal discs, fields and van Herick). b. Patients aged 65 and over with IOPs of <25mmHg and with otherwise normal ocular examinations (normal discs, fields and van Herick). These groups do not qualify for treatment under current NICE guidance. Such patients may be advised that they should be reviewed by a community optometrist every 12 months.

6 Combined Referral criteria > CCT micrometres micrometres <555 micrometres Any IOP (mmhg) >21-25 >25-29 >21-25 >25-29 >21-25 >25-29 >30 Refer if Refer if Refer if Referral No No No <60 <65 <80 Refer

7 Referral Criteria Combined criteria IOP CCT and Age See table Disc & Visual Field Show definite glaucomatous Change disc and field consistent Change in ONH Change in cup size of >0.2 OR Change in ISNT rule

8 Referral Criteria Other Glaucomas Secondary glaucoma Narrow angles Pseudoexfoliation Anterior Segme nt change with IOP >21mmHg on 2 occasions Van Herrick grade 1 or less OR Gonioscopy shows occludab le angle Treat as open angle glaucoma with yearly follow - up

9 GERS criteria Single referral criteria IOP >30*mmHg confirmed at a second visit. If IOP >35 mmhg then no confirmatory measurement is necessary Unequivocal pathological cupping at the optic nerve head. Abnormal neuroretinal rim configuration. Large cup, taking into account the overall size of the disc. Notched neuroretinal rim. A >0.2 asymmetry of cup to disc ratio Visual field loss consistent with a diagnosis of glaucoma, confirmed at a second visit. If VF explained by non-glaucomatous disc or retinal pathology or neurological type defect to be referred as such and not through scheme. Refer for an optic disc haemorrhage through the referral refinement scheme only where there are additional optic disc and/or other glaucoma indicators. (Optic disc alone without glaucomatous features should be referred to the GP as for other pathology)

10 Referral Criteria If patient under 40years with suspect developmental or secondary glaucoma or early onset glaucoma then phone/fax for advice.

11 New NICE Guidance Supports before referral: 1 st Nov 2017 Use of Goldmann-type tonometry Automated Perimetry Dilated Biomicroscopy for Disc assessment A/C Depth Assessment Repeating tests Providing all examination results with referral Commissioning of Referral Filtering Services Not referring people who have previously been discharged from hospital eye services unless clinical circumstances have changed and a new referral is needed. [2017]

12 New NICE Guidance 1 st Nov 2017 Supports for discharge to primary care: People referred for OHT who do not require treatment People referred with suspected glaucoma when this is no longer suspected Provision of discharge summary to patient, GP and nominated primary eye care professional Patients discharged to primary care are not intended to be monitored regular routine eye checks

13 Variances to GERS with New NICE Guidance Referral threshold > 24mmHG No age thresholds for referral No CCT thresholds for referral

14 However Not all people with IOP > 24mmHg will receive treatment CCT important at point of diagnosis to assess risk of conversion/progression Age still relevant when assessing risk of visual impairment in patients lifetime

15 Current Status Further discussions between Ophthalmologists, Community Optomerists and CCG regarding keeping or modifying the referral criteria going forward The Manchester GERS referral criteria stands as it is Pachymetry will form part of the assessment 2 year implementation window for NICE

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17 College Advice

18 Monitoring People with OHT, suspected COAG or COAG should have monitoring and treatment from a trained healthcare professional who has all of the following: a specialist qualification relevant experience ability to detect a change in clinical status. [2009, amended 2017]

19 1.6.3 Be aware that holding an independent or non-medical prescribing qualification alone (without a specialist qualification relevant to the case complexity of glaucoma being managed) is insufficient for managing glaucoma and related conditions.

20 1.6.8 Healthcare professionals who diagnose, treat or monitor independently of consultant ophthalmologist supervision should take full responsibility for the care they provide. [2009]

21 NICE Quality Standards Healthcare professionals ensure they discharge people with suspected COAG or with OHT who are not recommended for treatment and whose condition is considered stable from formal monitoring with a patient-held management plan.