1. Clinical Guidance and Monitoring for Change Cecilia Fenerty MD FRCOphth

2. Original GRR Referral criteria Single criteria IOP Visual Fields Disc >26mmHg on 2 occasions >35 mmHg requires urgent referral Defect on 2 occasions not explained by other pathology Pathological cupping (notch, abnormal NRR, large cup for disc size, disc haemorrhage) Asymmetry of >0.2 between the 2 eyes

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. New GRR 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)

7. Combined Referral criteria

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

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

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

11. Monitoring IOP Disc imaging Automated visual field Additional ocular Pathology

12. 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.

13. Monitoring of patients on no treatment