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Glaucoma

Checked: 23-08-2021 by Sandi Littler Next Review: 23-04-2022

Who to refer

Urgent Referrals

Symptoms suggestive of intermittent angle closure in the context of angles at risk of closure (intermittent pain, blurring, haloes, brow ache)
Advanced glaucomatous visual field loss
Advanced glaucomatous optic nerve damage
Known glaucoma patients not tolerating their eye drops
Progression of glaucoma in any patient under the community monitoring scheme

Routine Referrals

Suspected glaucomatous optic disc damage
Repeatable glaucomatous visual field loss
Suspected narrow angles without symptoms

Please note that Raised Intraocular Pressure referrals are subject to a Raised Intraocular Pressure Criteria Based Access (CBA) Policy and will be rejected if:

IOP <24mmHg and normal optic discs and visual fields
IOP <24 and insufficient information on disc status or visual field status
Pigment dispersion syndrome or pseudoexfoliation without raised pressures or glaucoma (PDS/PXF do increase risk of glaucoma so should have yearly sight tests)

Patients with with IOP below 24 mmHg without any features of glaucoma should be advised to continue regular visits to their primary eye care professional.

Red Flags

Immediate (same day) referral to the BEH Emergency Department:

if intraocular pressure (IOP) > 35mmHg of any cause (including acute (angle closure) glaucoma)
for suspected Bleb-related Infection

A bleb refers to the surgical drainage area which is created under the conjunctiva after any surgical drainage operation for glaucoma. There is a risk of infection to the bleb at any given time post op, short and long term. Patients present with loss of vision, extreme pain and redness. This is an emergency as there is high risk for acute onset endophthalmitis. Patients need to be send to BEH A&E urgently.

Before referral

Patients presenting with visual loss may need to stop driving if minimum standards are not met and may need to inform the Driver and Vehicle Licensing Agency (DVLA).

Repeat pressure check with Goldmann Applanation Tonometry (GAT) and repeat perimetry (visual fields testing) must be carried out for all new patient glaucoma referrals. This is usually performed by accredited optometrists and improves the quality of referrals significantly.

It is protocol to send back to the referring optometrist if the measurements has not been done. BEH will reject a referral where this has not been done, particularly if a positive visual field defect has been identified but there is no attached document demonstrating this defect. If the visual fields are normal then a report confirming this is usually accepted.

Do not base a decision to refer solely on IOP measurement using non-contact tonometry.

As per NICE guidelines, before deciding to refer, consider repeating visual field assessment and IOP measurement on another occasion to confirm a visual field defect or IOP of 24 mmHg or more, unless clinical circumstances indicate urgent or emergency referral is needed.

Treatments of Glaucoma can be found in the BNSSG Adult Joint Formulary section on Remedy.

Services

Refer via eRS. There is a choice of providers.

If the patient has long-term follow-up by a provider for a condition that may also be affected by your referral, please consider referring to the same provider for continuity of care.

Resources

NICE guideline [NG81] Glaucoma: diagnosis and management

BEH Referral Guidance Document 2023

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.