1. Implementing NICE guidancev
Glaucoma
Implementing NICE guidance
This slide set was updated in May 2011 and now includes the NICE Quality Standard.
ABOUT THIS PRESENTATION:
This presentation has been written to help you raise awareness of the NICE clinical guideline on ‘Glaucoma: diagnosis and management of chronic open angle glaucoma and ocular hypertension’ and the glaucoma quality standard.
The guideline has been written for ophthalmologists, optometrists, orthoptists, pharmacists, nurses, GPs and other staff who care for people with ocular hypertension or glaucoma.
The guideline is available in a number of formats, including a quick reference guide. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. See the end of the presentation for ordering details.
You can add your own organisation’s logo alongside the NICE logo.
We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
PROMOTING EQUALITY
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
Slide set updated May 2011
NICE clinical guideline 85

2. What this presentation covers
Background Scope Key priorities for implementation Costs and savings Discussion Find out more NICE Quality standard
NOTES FOR PRESENTERS:
In this presentation we will start by providing some background to the guideline and why it is important.
We will then present the key priorities for implementation. The NICE guideline contains ten key priorities for implementation.
The key priorities for implementation cover the following areas:
diagnosis
monitoring
treatment for people with ocular hypertension (OHT) or suspected chronic open angle glaucoma (COAG)
treatment for people with COAG
organisation of care
provision of information.
Next, we will summarise the costs and savings that are likely to be incurred in implementing the guideline.
Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice.
Finally, we will end the presentation with further information about the support provided by NICE.
Slides are also provided which summarise the NICE Quality Standard

3. Background
Chronic open angle glaucoma (COAG) is a common and potentially blinding condition, and is usually asymptomatic until advanced
Ocular hypertension (OHT) is a major risk factor for developing COAG
Approximately 10% of UK blindness registrations are attributed to glaucoma
By implementing this guideline more people will be prevented from going blind
NOTES FOR PRESENTERS:
Key points to raise:
Around 2% of people over 40 years have COAG, rising to almost 10% in people over 75 years in white Europeans. The prevalence may be higher in people of black African or black Caribbean descent or people who have a family history of glaucoma. With changes in population demographics the number of people affected is expected to rise. Based on these estimates 480,000 people are currently affected by COAG in England.
Once diagnosed, people with COAG need lifelong monitoring so that any progression of visual damage can be detected. Controlling the condition to prevent or minimise further damage is crucial to maintaining a sighted lifetime.
Additional information:
National policy drivers that may have an impact at a local level:
NHS eye care services programme 2002–2008 – The programme worked with the NHS to provide national facilitation and coordination for the testing and development of eye care pathways, including a pathway for glaucoma which was piloted in four areas.
Department of Health (DH) (2007) ‘Commissioning toolkit for community based eye care services’ – The toolkit provides primary care trusts (PCTs) and practice-based commissioners with practical advice on commissioning community-based eye care services, drawing on evidence from the evaluated pilots of pathways (which include glaucoma).
Primary Care Contracting (2007) ‘Community eye care services: review of local schemes for low vision, glaucoma and acute care’ – This is a review of local examples of community eye care services and complements the commissioning toolkit (see above).
Primary Care Contracting (2007) ‘Step by step guide to commissioning community eye care services’ (update July 2008) – This guide provides information and practical tools for PCTs and practice-based commissioners.
Vision 2020 UK (2008) ’UK Vision Strategy. Setting the direction for eye health and sight loss services’ – This is a Vision 2020 UK initiative to develop a unified plan for action on all issues relating to vision.
National Patient Safety Agency (2009) – The agency has issued a Rapid Response Report that urges organisations to review their systems and processes for booking follow-up appointments for people with glaucoma to ensure that they are made and kept in accordance with the treating clinician’s request and the patient’s clinical need.

4. Scope
The diagnosis and management of people with COAG and OHT in community, primary care, secondary care outpatient and day treatment services and tertiary care specialist services for people in the following groups:
adults (18 and older) with a diagnosis of COAG or OHT
people with chronic open angle glaucoma or ocular hypertension associated with pseudoexfoliation or pigment dispersion
people who have a higher prevalence of glaucoma and may have worse clinical outcomes
NOTES FOR PRESENTERS:
Key points to raise:
Glaucoma is a disease of the optic nerve with characteristic changes in the optic nerve head and visual field defects, with or without raised intraocular pressure (IOP).
COAG is glaucoma without evident secondary cause, which is chronic and occurs in the presence of an open anterior chamber angle, including COAG associated with pseudoexfoliation and pigment dispersion.
Glaucoma is suspected when, regardless of the level of the IOP, the optic nerve head and/or visual field show changes that suggest possible glaucomatous damage.
Ocular hypertension is a consistently or recurrently elevated intraocular pressure (greater than 21 mmHg) with no clinical evidence of optic nerve damage or visual field defect.
People who have a higher prevalence of glaucoma and may have worse clinical outcomes are:
people with a family history of glaucoma
people younger than 50 years
people who are of black African or black Caribbean descent.
Groups not covered by the guideline are:
people younger than 18 years
people with secondary glaucoma (for example neovascular or uveitic) except for those described above
people with, or at risk of, primary or secondary angle closure glaucoma
adults with primary congenital, infantile or childhood glaucoma.

5. Key priorities for implementation

6. Diagnosis
At diagnosis offer all people who have COAG, who are suspected of having COAG or who have OHT all of the following tests:
intraocular pressure (IOP) measurement using Goldmann applanation tonometry (slit lamp mounted)
central corneal thickness (CCT) measurement
peripheral anterior chamber configuration and depth assessments using gonioscopy
visual field measurement using standard automated perimetry (central thresholding test)
optic nerve assessment, with dilatation, using stereoscopic slit lamp biomicroscopy with fundus examination
NOTES FOR PRESENTERS:
Key points to raise:
Intraocular pressure (IOP) – The internal pressure of the fluid contained within the eye.
Adopt professional/Department of Health guidance to reduce the risk of transmitting infective agents via contact tonometry or gonioscopy.
Royal College of Ophthalmologists ( and the Medicines and Healthcare products Regulatory Agency (
See (1.1.2)

7. Diagnosis
Ensure that all of the following are made available at each clinical episode to all healthcare professionals involved in a person’s care:
records of all previous tests and images relevant to COAG and OHT assessment
records of past medical history which could affect drug choice
current systemic and topical medication
glaucoma medication record
drug allergies and intolerances
NOTES FOR PRESENTERS:
Key points to raise:
Use alternative methods of assessment if clinical circumstances rule out the use of standard methods of assessment (for example, when people with physical or learning disabilities are unable to participate in the examination). (1.1.6)

8. Monitoring Monitor at regular intervals people with OHT or
suspected COAG recommended to receive
medication (see ‘Treatment for people with OHT or
suspected COAG’), according to their risk
of conversion to COAG (see next slide)
NOTES FOR PRESENTERS:
Key points to raise:
Conversion to COAG – Worsening of suspected COAG or OHT with the development of visual field loss in keeping with optic nerve head appearance. To make this judgement the healthcare professional must know the eye’s earlier clinical state.
Discuss the benefits and risks of stopping treatment with people with OHT or suspected COAG who have both:
a low risk of ever developing visual impairment within their lifetime
an acceptable IOP.
If a person decides to stop treatment following discussion of the perceived risks of future conversion to COAG and sight loss, offer to assess their IOP in 1 to 4 months’ time with further monitoring if considered clinically necessary. (1.2.11)
In people with OHT or suspected COAG who are not recommended to receive medication, assess IOP, optic nerve head and visual field at the following intervals:
between 12 and 24 months if there is a low risk of conversion to COAG
between 6 and 12 months if there is a high risk of conversion to COAG.
If no change in the parameters has been detected after 3 to 5 years (depending on perceived risk of conversion), or before if confirmed normal, the person should be discharged from active glaucoma care to community optometric care. (1.2.12)
At discharge advise people who are not recommended for treatment and whose condition is considered stable to visit their primary care optometrist annually so that any future changes in their condition can be detected. (1.2.13)
Paragraphs to of the guideline describe the technical aspects of monitoring.

9. Monitoring intervals (months)
Monitoring intervals for people with OHT/suspected COAG recommended to receive medication
Clinical assessment
Monitoring intervals (months)
IOP at targeta
Risk of conversion to COAGb
Outcomec
IOP aloned
IOP, optic nerve head and visual field
Yes
Low
No change in treatment plan
Not applicable
12 to 24
High
6 to 12 No
Review target IOP or change treatment plan
1 to 4
4 to 6
NOTES FOR PRESENTERS:
Key points to raise:
a Person is treated and IOP is at or below target. If IOP cannot be adequately controlled medically, refer to consultant ophthalmologist.
b To be clinically judged in terms of age, IOP, central corneal thickness (CCT), appearance and size of optic nerve head.
c For change of treatment plan refer to treatment recommendations.
d For people started on treatment for the first time check IOP 1 to 4 months after start of medication.
Target IOP – A dynamic, clinical judgement about what level of IOP is considered by the healthcare professional treating the person to be sufficiently low to minimise or arrest disease progression or onset and avoid disability from sight loss within a person’s expected lifetime.

10. Monitoring Monitor at regular intervals people with COAG
according to their risk of progression to sight loss (see next slide)
NOTES FOR PRESENTERS:
Key points to raise:
Progression – The worsening of COAG as clinically judged by the healthcare professional caring for the person on the basis of the assessment of visual field loss and optic nerve head appearance. To make this judgement the healthcare professional must know the eye’s earlier clinical state.
Monitoring intervals have been specified for COAG follow-up, which should help resolve the widespread delays in follow-up appointments which are currently a significant problem.
National Patient Safety Agency (2009) – The agency has issued a Rapid Response Report that urges organisations to review their systems and processes for booking follow-up appointments for people with glaucoma to ensure that they are made and kept in accordance with the treating clinician’s request and the patient’s clinical need.

11. Monitoring intervals (months)
Monitoring intervals for people with COAG
Clinical assessment
Monitoring intervals (months)
IOP at targeta
Progressionb
Outcomec
IOP aloned
IOP, optic nerve head and visual field
Yes
Noe
No change in treatment plan
Not applicable
6 to 12
Review target IOP and change treatment plan
1 to 4
2 to 6
Uncertain No
Review target IOP or change treatment plan
Yes/uncertain
Change treatment plan
1 to 2
NOTES FOR PRESENTERS:
Key points to raise:
a IOP at or below target.
b Progression = increased optic nerve damage and/or visual field change confirmed by repeated test where clinically appropriate.
c For change of treatment plan refer to treatment recommendations.
d For people started on treatment for the first time check IOP 1 to 4 months after start of medication.
e No = not detected or not assessed if IOP check only following treatment change.

12. Treatment for people with OHT or suspected COAG
Offer people with OHT or suspected COAG
with high IOP treatment based on estimated
risk of conversion to COAG using IOP, CCT
and age (see next slide)

13. Treatment for people with OHT or suspected COAG
CCT
More than 590 micrometres
555–590 micrometres
Less than 555 micrometres
Any
Untreated IOP (mmHg)
> 21 to 25
> 25 to 32
>25 to 32
> 32
Age (years)a
Treat until 60
Treat until 65
Treat until 80
Treatment
No treatment
BBb
PGA
NOTES FOR PRESENTERS:
Key points to raise:
a Treatment should not be routinely offered to people over the age threshold unless there are likely to be benefits from the treatment over an appropriate timescale. Once a person being treated for OHT reaches the age threshold for stopping treatment but has not developed COAG, healthcare professionals should discuss the option of stopping treatment.
The use of age thresholds is considered appropriate only where vision is currently normal (OHT with or without suspicion of COAG) and the treatment is purely preventative. Under such circumstances the threat to a person’s sighted lifetime is considered negligible. In the event of COAG developing in such a person then treatment is recommended.
b If beta-blockers (BB) are contraindicated offer a prostaglandin analogue (PGA).
BB: betablocker
PGA: prostaglandin analogue

14. Treatment for people with COAG
Offer people newly diagnosed with early or moderate COAG, and at risk of significant visual loss in their lifetime, treatment with a prostaglandin analogue
Offer surgery with pharmacological augmentation (mitomycin C [MMC] or 5-fluorouracil [5-FU]) as indicated to people with COAG who are at risk of progressing to sight loss despite treatment. Offer them information on the risks and benefits associated with surgery
NOTES FOR PRESENTERS:
Key points to raise:
At the time of publication (April 2009), mitomycin C (MMC) and 5-fluorouracil (5-FU) did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. Both drugs should be handled with caution and in accordance with guidance issued by the Health and Safety Executive.

15. Organisation of care
Refer people with suspected optic nerve damage or repeatable visual field defect, or both, to a consultant ophthalmologist for consideration of a definitive diagnosis and formulation of a management plan
People with a diagnosis of OHT, suspected COAG or COAG should be monitored and treated by a trained healthcare professional who has all of the following:
a specialist qualification (when not working under the supervision of a consultant ophthalmologist)
relevant experience
ability to detect a change in clinical status
NOTES FOR PRESENTERS:
Key points to raise:
Ocular hypertension (OHT) Consistently or recurrently elevated IOP (greater than 21 mmHg) in the absence of clinical evidence of optic nerve damage or visual field defect.
People with a confirmed diagnosis of OHT or suspected COAG and who have an established management plan may be monitored (but not treated) by a suitably trained healthcare professional with knowledge of OHT and COAG, relevant experience and ability to detect a change in clinical status. The healthcare professional should be able to perform and interpret all of the following:
Goldmann applanation tonometry (slit lamp mounted)
standard automated perimetry (central thresholding test)
central supra-threshold perimetry (this visual field strategy may be used to monitor people with OHT or COAG suspect status when they have normal visual field)
stereoscopic slit lamp biomicroscopic examination of the anterior segment
Van Herick’s peripheral anterior chamber depth assessment
examination of the posterior segment using slit lamp binocular indirect ophthalmoscopy.
(1.5.6)

16. Provision of information
Offer people the opportunity to discuss their
diagnosis, prognosis and treatment, and
provide them with relevant information in an
accessible format at initial and subsequent
visits
NOTES FOR PRESENTERS:
Key points to raise:
Provision of information may include the following:
their specific condition (OHT, suspected COAG and COAG), its life-long implications and their prognosis for retention of sight
that COAG in the early stages and OHT and suspected COAG are symptomless
that most people treated for COAG will not go blind
that once lost, sight cannot be recovered
that glaucoma can run in families and that family members may wish to be tested for the disease
the importance of the person’s role in their own treatment – for example, the ongoing regular application of eye drops to preserve sight
the different types of treatment options, including mode of action, frequency and severity of side effects, and risks and benefits of treatment, so that people are able to be active in the decision-making process
how to apply eye drops, including technique (punctal occlusion and devices) and hygiene (storage)
the need for regular monitoring as specified by the healthcare professional
methods of investigation during assessment
how long each appointment is likely to take and whether the person will need any help to attend (or example, driving soon after pupil dilatation would be inadvisable)
support groups
compliance aids (such as dispensers) available from their GP or community pharmacist
Letter of Vision Impairment (LVI), Referral of Vision Impairment (RVI) and Certificate of Vision Impairment (CVI) registration
Driver and Vehicle Licensing Agency (DVLA) regulations.

17. Costs and savings per 100,000 population
Recommendations with significant costs
Costs (£ per year)
Monitoring and treatment of people with OHT or suspected COAG
20,820
Surgery for people who have COAG progression despite treatment
3808
Estimated incremental cost of implementation
24,628
Potential resource shift as a result of implementation
Potential resource shift (£ per year)
Demand pressures reduced in hospital eye service from potential resource shift to community
–14,661
Estimated cost of shifting services to the community
14,661
ADAPTING THIS SLIDE FOR LOCAL USE:
We are aware that local factors such as incidence and baseline can vary considerably when compared with the national average. NICE has provided a costing template for you to calculate the financial impact this guideline will have locally. We encourage you to calculate the local impact of this guideline by amending the local variations in the template such as incidence, baseline and uptake. You can then remove the national figures from the table and replace them with your local figures to present to your colleagues.
NOTES FOR PRESENTERS:
NICE has worked closely with people within and outside the NHS to look at the major costs and savings related to implementing this guideline.
The estimated national annual changes in costs arising from implementing the guideline on glaucoma are £13 million nationally. This comprises £11 million relating to the monitoring and treatment of people with OHT or suspected COAG and £2 million relating to additional demand for surgery.
There may be a resource shift from the hospital eye service to the community as a result of increased workload relating to the monitoring and treatment for people with OHT or suspected COAG. The potential for this is also in line with DH proposals to address demand pressures and accessibility for hospital eye services. The costing report estimates that the potential shift from the hospital eye service to the community could be in the region of £7.4 million nationally. This only relates to people with OHT, suspected COAG and people with COAG who can be managed in the community, and where the conditions in recommendations and are met. The national tariff for outpatient visits to ophthalmology departments has been used to estimate costs. This may differ from local costs for community services, therefore estimates need to be reviewed locally.
The costing report also recognises that time and investment is needed to ensure that the training, qualifications audit and governance arrangements and the necessary support is provided when creating the additional capacity to deliver services. The estimated timeframe for implementation is therefore 3 years, however this could be up to 5 years depending on local circumstances.
NICE has produced a costing report that provides detailed estimates of the national costs and savings associated with implementing this guideline. NICE has also developed a costing template to calculate the local costs associated with implementing this guideline. The costs per 100,000 population are summarised in the table.
For further information please refer to the costing template and costing report for this guideline on the NICE website.

18. Costs and potential resource shift
Recommendations in the following areas may result in additional costs depending on local circumstances:
more regular monitoring and treatment of people with OHT or suspected COAG
surgery for people who have COAG progression despite treatment as a result of improved sequential data
potential resource shift from hospital eye services to community (where appropriate) as a result of increased monitoring of people with OHT and suspected COAG
NOTES FOR PRESENTERS:
Different areas may vary from the national average and it is important to look at the recommendations most likely to have a resource impact to make sure that local practice matches the national average.
These recommendations are:
Monitor at regular intervals people with OHT or suspected COAG recommended to receive medication according to their risk of conversion to COAG
Current care pathways for people with OHT or suspected COAG are inconsistent. The recommendation provides for more thorough and more regular monitoring intervals for this group. This is likely to increase the workload of eye care services and have significant resource impact.
1.4.7 Offer surgery with pharmacological augmentation (MMC or 5-FU) as indicated to people with COAG who are at risk of progressing to sight loss despite treatment. Offer them information on the risks and benefits associated with surgery.
There may be an increase in the demand for surgery as a result of recommendation When combined with the improved availability of quality sequential data provided for in recommendation this may result in earlier identification of glaucoma progression and increased demand for surgery.
1.5.6 People with a confirmed diagnosis of OHT or suspected COAG and who have an established management plan may be monitored (but not treated) by a suitably trained healthcare professional with knowledge of OHT and COAG, relevant experience and ability to detect a change in clinical status. The recommendation goes on to describe the tests healthcare professionals should be able to perform and interpret.
There may be scope to shift services to the community where this is appropriate, safe and will benefit the patient. The knock-on effect of recommendation may result in further workload pressures on the hospital eye service, therefore other options for service configuration may need to be explored. Section 1.5 of the guideline relating to organisation of care ensures that quality and standards of care are maintained where trained healthcare professionals who meet the requirements of the recommendation do not work under the supervision of a consultant ophthalmologist (recommendation 1.5.4). Recommendation also provides for the monitoring (but not treatment) of people diagnosed with OHT or suspected COAG by a suitably trained healthcare professional. An established management plan needs to be in place for the patient in order for this to happen, and the healthcare professional must have relevant experience and the ability to detect a change in clinical status.
The potential cost of shifting services to the community, along with issues for consideration, are explored in the costing tools. The costing tools do not specify service delivery options as these cannot be predicted and costed at national level and depend on local circumstances.
The costing report estimates that implementation may take 3 years. This is because it will take time and investment to ensure any additional capacity is delivered in a safe and effective manner, whether this is within the hospital eye service or the community.

19. Discussion How effective are local diagnostic services?
What changes might we need to make to achieve the monitoring intervals for each patient group?
What are the options that local commissioners might consider for delivering this guideline?
How are patient information needs currently met?
NOTES FOR PRESENTERS:
These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.
How effective are local diagnostic services?
What changes might we need to make to achieve the monitoring intervals for each patient group?
How do local services manage glaucoma follow-up intervals currently? How many patients currently fall outside the recommended follow-up intervals? What initiatives can be set up to improve the timely delivery of glaucoma review intervals? What additional costs will be involved?
What are the options that local commissioners might consider for delivering this guideline?
What glaucoma service initiatives (for example, ‘shared care schemes’, referral refinement schemes) already exist locally? Do these local models fit with NICE guidance? What needs to be changed in order to meet NICE guidance? Do these schemes need to be expanded to meet the local service demand? What additional costs will be involved? Do we need to consider alternative service models? What other issues need to be taken into account when considering different service models (for example when considering ‘shared care schemes’, local organisations will need to think about funding and training for professionals involved in these schemes, ensuring that the right equipment and mechanisms for record sharing are available)?
How are patient information needs currently met?

20. Find out more Visit www.nice.org.uk/CG85 for: the guideline
the quick reference guide
‘Understanding NICE guidance’
NICE Pathway
costing report and template
audit support
commissioning guide
online educational tool
Glaucoma Quality Standard can be found at
NOTES FOR PRESENTERS:
You can download the guidance documents from the NICE website.
The NICE guideline – all the recommendations.
A quick reference guide – a summary of the recommendations for healthcare professionals.
‘Understanding NICE guidance’ – information for patients and carers.
The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on.
For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on or and quote reference numbers N1846 (quick reference guide) and/or N1847 (‘Understanding NICE guidance’).
NICE has produced a NICE Pathway for this topic, which visually represents everything NICE has to say on Glaucoma, so you can see all our recommendations at a glance.
NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.
Costing tools – a costing report gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved.
Audit support – for monitoring local practice.
Commissioning guide – to signpost and provide information on key clinical and service-related issues to consider during the commissioning process, including a commissioning tool that can be used to estimate and inform the level of service needed locally as well as the cost of local commissioning decisions.
Online educational tool – developed in conjunction with BMJ Learning, the interactive module guides participants through a real life consultation.

21. Glaucoma www.nice.org.uk/guidance/qualitystandards/glaucoma/Home.jsp
NICE Quality Standard
Glaucoma
This section of the slide set provides a summary of the NICE quality standards for glaucoma. For full details of the quality standards refer to the Glaucoma Quality Standard page on the NICE website

22. Quality standards
A quality standard is a set of specific, concise statements that:
act as markers of high-quality, cost-effective patient care across a pathway or clinical area, covering treatment and prevention
are derived from the best available evidence such as NICE guidance or other NHS evidence accredited sources and produced collaboratively with the NHS and social care, along with their partners and service users.
NOTES FOR PRESENTERS:
Key points to raise:
There are two components to a quality standard. These are qualitative statements and quantitative measures. Quality standards also include audience descriptors, definitions and data sources which support the statement measures.
Qualitative statements are descriptive statements of the key infrastructure and clinical requirements for high quality care, as well as the desirable or expected outcomes.
Commissioners will be interested in quality standards as markers of high quality care and patients and the public will see clear statements of what they can expect to receive from high quality services.

23. Glaucoma quality standard
The glaucoma quality standard consists of 12 statements that describe the care for people with chronic open angle glaucoma (COAG), suspected COAG or ocular hypertension (OHT).
Desired outcomes are to:
enhance the quality of life for people with COAG
ensure people have a positive experience of care
treat and care for people in a safe environment
contribute to a reduction in Certificate of Visual Impairment registration rates for glaucoma.
Scope
Care for people with chronic open angle glaucoma (COAG), suspected COAG or with ocular hypertension (OHT).
Outcomes
COAG, suspected COAG and OHT are common conditions which, if not diagnosed and managed correctly, can lead to partial sightedness (sight impairment) and blindness (severe sight impairment). This quality standard describes markers of high-quality, cost-effective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience of care for people with COAG, suspected COAG or with OHT in the following ways
Enhancing quality of life for people with long-term conditions.
Ensuring that people have a positive experience of care.
Treating and caring for people in a safe environment and protecting them from avoidable harm.
NHS Outcomes Framework 2011/12 is available from
Specifically, it is expected that achieving the high-quality care set out in this quality standard will contribute to a reduction in Certificate of Visual Impairment (CVI)  registration rates for patients who are sight impaired and severely sight impaired.

24. Quality statement 1- Referral
People are referred to a consultant ophthalmologist for further assessment and definitive diagnosis if the optometrist or other healthcare professional suspects COAG. There are local agreements in place for referral refinement.
Quality measure
Process:
a) Proportion of people in whom an optometrist or other healthcare
professional suspects COAG who undergo further assessment
with referral refinement.
b) Proportion of people who undergo referral refinement who are
subsequently referred on to a consultant ophthalmologist for
definitive diagnosis because COAG is suspected.
Quality measure
Structure: Evidence of arrangements for referral refinement that ensure people are referred to a consultant ophthalmologist for further assessment and definitive diagnosis if the optometrist or other healthcare professional suspects chronic open angle glaucoma (COAG).
Process:
a) Proportion of people in whom an optometrist or other healthcare professional suspects COAG who undergo further assessment with referral refinement.
Numerator – the number of people in the denominator who undergo further assessment with referral refinement.
Denominator – the number of people in whom an optometrist or other healthcare professional suspects COAG.
b) Proportion of people who undergo referral refinement who are subsequently referred on to a consultant ophthalmologist for definitive diagnosis because COAG is suspected.
Numerator – the number of people in the denominator who are referred to a consultant ophthalmologist for definitive diagnosis.
Denominator – the number of people undergoing referral refinement because COAG is suspected.
Description of what the quality statement means for each audience: Refer to the Glaucoma Quality Standard
Source clinical guideline references: College of Optometrists and Royal College of Ophthalmologists. Guidance on the referral of glaucoma suspects by community optometrists recommendations 5 and 6
Definitions: Refer to Glaucoma Quality Standard for definition of ‘referral refinement’ and features of COAG.

25. Quality statement 2 - Referral
People with elevated IOP alone are referred to an appropriately qualified healthcare professional for further assessment on the basis of perceived risk of progression to COAG. There are agreements in place for repeat measures.
Quality measure
Process:
a) Proportion of people with elevation of IOP alone, who are
referred for repeat measures to an appropriately qualified
healthcare professional.
b) Proportion of people with confirmed elevation of IOP alone, who
are referred to an appropriately qualified healthcare professional
for further assessment on the basis of perceived risk of
progression to COAG.
Quality measure
Structure: Evidence that there are agreements in place for repeat measures to ensure that people with confirmed elevation of intraocular pressures (IOP) alone (normal optic discs and visual fields) are referred to an appropriately qualified healthcare professional for further assessment on the basis of perceived risk of progression to chronic open angle glaucoma (COAG).
Process:
a) Proportion of people with elevation of IOP alone, who are referred for repeat measures to an appropriately qualified healthcare professional.
Numerator – the number of people in the denominator referred for repeat measures to an appropriately qualified healthcare professional.
Denominator – the number of people with suspected elevation of IOP alone.
b) Proportion of people with confirmed elevation of IOP alone, who are referred to an appropriately qualified healthcare professional for further assessment on the basis of perceived risk of progression to COAG.
Numerator – the number of people in the denominator referred to an appropriately qualified healthcare professional on the basis of perceived risk of progression to COAG.
Denominator – the number of people with confirmed elevation of IOP alone.
Description of what the quality statement means for each audience: Refer to the Glaucoma Quality Standard
Source clinical guideline references: College of Optometrists and Royal College of Ophthalmologists. Guidance on the referral of glaucoma suspects by community optometrists recommendations 5 and 6.
Definitions: : Refer to the Glaucoma Quality Standard for definition of ‘repeat measures’, elevation of IOP, an appropriately qualified healthcare professional and features suggestive of suspected COAG or OHT.

26. Quality statement 3 - Diagnosis
People referred for definitive diagnosis in the context of possible COAG or with OHT receive all relevant tests in accordance with NICE guidance.
Quality measure
Process:
Proportion of people referred for definitive diagnosis in
the context of possible COAG or with OHT who attend and
receive all relevant tests in accordance with NICE guidance.
Quality measure
Structure: Evidence of arrangements to ensure that people referred for definitive diagnosis in the context of possible COAG (chronic open angle glaucoma) or with OHT (ocular hypertension) receive all relevant tests in accordance with NICE guidance.
Process:
Proportion of people referred for definitive diagnosis in the context of possible COAG or with OHT who attend and receive all relevant tests in accordance with NICE guidance.
Numerator – the number of people in the denominator receiving all relevant tests in accordance with NICE guidance.
Denominator – the number of people attending an appointment following a referral for definitive diagnosis in the context of possible COAG or with OHT.
Description of what the quality statement means for each audience: Refer to the Glaucoma Quality Standard
Source clinical guideline references: NICE clinical guideline 85 recommendation (key priority for implementation).
Definitions: Refer to the Glaucoma Quality Standard for definition of relevant tests at diagnosis for COAG, suspected COAG and with OHT.
Equality and diversity considerations:
People with physical or learning disabilities may be unable to participate in some of the relevant diagnostic tests and therefore alternative tests should be offered.

27. Quality statement 4 – Diagnosis and management plan
People with COAG, suspected COAG or with OHT are diagnosed and have a management plan formulated by a suitably trained healthcare professional with competencies and experience in accordance with NICE guidance.
Quality measure
Process:
a) Proportion of people with COAG, suspected COAG or with OHT
who are diagnosed by a suitably trained healthcare professional
with competencies and experience in the relevant condition in
accordance with NICE guidance.
b) Proportion of people with COAG, suspected COAG or with OHT
who have a management plan formulated by a healthcare
professional with competencies and experience in the relevant
condition in accordance with NICE guidance.
Quality measure
Structure: Evidence of arrangements to ensure that people with chronic open angle glaucoma (COAG), suspected COAG or with ocular hypertension (OHT) are diagnosed and have a management plan formulated by a suitably trained healthcare professional with competencies and experience in the relevant condition in accordance with NICE guidance.
Process:
a) Proportion of people with COAG, suspected COAG or with OHT who are diagnosed by a suitably trained healthcare professional with competencies and experience in the relevant condition in accordance with NICE guidance.
Numerator – the number of people in the denominator diagnosed by a suitably trained healthcare professional with competencies and experience in the relevant condition in accordance with NICE guidance.
Denominator – the number of people with COAG, suspected COAG or with OHT.
b) Proportion of people with COAG, suspected COAG or with OHT who have a management plan formulated by a healthcare professional with competencies and experience in the relevant condition in accordance with NICE guidance.
Numerator – the number of people in the denominator with a management plan formulated by a healthcare professional with competencies and experience in the relevant condition in accordance with NICE guidance.
Description of what the quality statement means for each audience: Refer to the Glaucoma Quality Standard
Source clinical guideline references: NICE clinical guideline 85 recommendations 1.5.1, 1.5.2, (key priorities for implementation), 1.5.3, 1.5.5,
Definitions: Refer to the Glaucoma Quality Standard

28. Quality statement 5 - Monitoring
People diagnosed with COAG, suspected COAG or with OHT are monitored at intervals according to their risk of progressive loss of vision in accordance with NICE guidance.
Quality measure
Process:
Proportion of people with COAG, suspected COAG or
with OHT who are monitored at intervals according to their risk of
progressive loss of vision in accordance with NICE guidance.
Quality measure
Structure: Evidence of arrangements to ensure that people diagnosed with chronic open angle glaucoma (COAG), suspected COAG or with ocular hypertension (OHT) are monitored at intervals according to their risk of progressive loss of vision in accordance with NICE guidance.
Process:
Proportion of people with COAG, suspected COAG or with OHT who are monitored at intervals according to their risk of progressive loss of vision in accordance with NICE guidance.
Numerator – the number of people in the denominator monitored at intervals according to their risk of progressive loss of vision in accordance with NICE guidance.
Denominator – the number of people diagnosed with COAG, suspected COAG or with OHT.
Description of what the quality statement means for each audience: Refer to the Glaucoma Quality Standard
Source clinical guideline references: NICE clinical guideline 85 recommendation , (key priorities for implementation), , ,
Definitions: : Refer to the Glaucoma Quality Standard

29. Quality statement 6 - Management
People with suspected COAG or with OHT are managed based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age, in accordance with NICE guidance.
Quality measure
Process:
a) Proportion of people diagnosed with suspected COAG or with
OHT who are assessed for treatment eligibility based on estimated
risk of conversion to COAG and progression to visual impairment
using IOP, CCT and age.
b) Proportion of people diagnosed with suspected COAG or with
OHT who are eligible for treatment based on estimated risk of
conversion to COAG and progression to visual impairment using
IOP, CCT and age, who are managed in accordance with NICE
guidance.
Quality measure
Structure: Evidence of arrangements to ensure that people with suspected chronic open angle glaucoma (COAG) or with ocular hypertension (OHT) are managed based on estimated risk of conversion to COAG and progression to visual impairment using intraocular pressure (IOP), central corneal thickness (CCT) and age, in accordance with NICE guidance.
Process:
a) Proportion of people diagnosed with suspected COAG or with OHT who are assessed for treatment eligibility based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age.
Numerator – the number of people in the denominator assessed for treatment eligibility based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age.
Denominator – the number of people diagnosed with suspected COAG or with OHT.
b) Proportion of people diagnosed with suspected COAG or with OHT who are eligible for treatment based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age, who are managed in accordance with NICE guidance.
Numerator – the number of people in the denominator managed in accordance with NICE guidance.
Denominator – the number of people diagnosed with suspected COAG or with OHT who are eligible for treatment based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age.

30. Quality statement 6 – Management cont.
People with suspected COAG or with OHT are managed based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age, in accordance with NICE guidance.
Quality measure
Process:
c) Proportion of people diagnosed with suspected COAG or with
OHT at low risk of progressing to visual impairment who receive
no treatment in accordance with NICE guidance.
c) Proportion of people diagnosed with suspected COAG or with OHT at low risk of progressing to visual impairment who receive no treatment in accordance with NICE guidance.
Numerator – the number of people in the denominator who receive no treatment in accordance with NICE guidance.
Denominator – the number of people diagnosed with suspected COAG or with OHT at low risk of progressing to visual impairment for whom treatment is not recommended by NICE guidance.
Description of what the quality statement means for each audience: Refer to the Glaucoma Quality Standard
Source clinical guideline references: NICE clinical guideline 85 recommendation (key priority for implementation) and recommendation
Definitions: : Refer to the Glaucoma Quality Standard

31. Quality statement 7 – Stopping treatment
People with COAG, suspected COAG or with OHT have a regular review of management options with their healthcare professional, taking into account comorbidity and other changed circumstances, including a discussion of the benefits and risks of stopping treatment for those at low risk of progressing to visual impairment.
Quality measure
Process:
a) Proportion of people with COAG, suspected COAG or with OHT
who have a regular review of management options with their
healthcare professional taking into account comorbidity and other
changed circumstances.
b) Proportion of people with COAG, suspected COAG or with OHT
at low risk of progressing to visual impairment who have a
discussion of the benefits and risks of stopping treatment.
Quality measure
Structure: Evidence of arrangements to ensure that people with chronic open angle glaucoma (COAG), suspected COAG or with ocular hypertension (OHT) have a regular review of management options with their healthcare professional, taking into account comorbidity and other changed circumstances, including a discussion of the benefits and risks of stopping treatment for those at low risk of progressing to visual impairment.
Process:
a) Proportion of people with COAG, suspected COAG or with OHT who have a regular review of management options with their healthcare professional taking into account comorbidity and other changed circumstances.
Numerator – the number of people in the denominator having a regular review of management options with their healthcare professional taking into account comorbidity and other changed circumstances.
Denominator – the number of people with COAG, suspected COAG or with OHT.
b) Proportion of people with COAG, suspected COAG or with OHT at low risk of progressing to visual impairment who have a discussion of the benefits and risks of stopping treatment.
Numerator – the number of people in the denominator participating in a discussion of the benefits and risks of stopping treatment.
Denominator – the number of people with COAG suspected COAG or with OHT at low risk of progressing to visual impairment.
Description of what the quality statement means for each audience: Refer to the Glaucoma Quality Standard
Source clinical guideline references: NICE clinical guideline 85 recommendations (key priority for implementation),
Definitions: Refer to the Glaucoma Quality Standard for definitions.

32. Quality statement 8 – Service capacity
People diagnosed with COAG, suspected COAG or with OHT have access to timely follow-up appointments and specialist investigations at intervals in accordance with NICE guidance. Sufficient capacity is put in place to provide this service, and systems are developed to identify people needing clinical priority if appointments are cancelled, delayed or missed.
Quality measure
Process:
a) Proportion of people with COAG, suspected COAG or with OHT
who have access to timely follow-up appointments and specialist
investigations at appropriate intervals in accordance with NICE
guidance.
b) Proportion of people with COAG, suspected COAG or with
OHT, whose appointment has been cancelled, delayed or missed
who have their clinical priority assessed.
Quality measure
Structure:
a) Evidence of arrangements to ensure people diagnosed with chronic open angle glaucoma (COAG), suspected COAG or with ocular hypertension (OHT) have access to timely follow-up appointments and specialist investigations in accordance with NICE guidance.
b) Evidence of arrangements to ensure sufficient capacity is put in place to provide this service and systems are developed to identify people needing clinical priority if appointments are cancelled, delayed or missed.
Process:
a) Proportion of people with COAG, suspected COAG or with OHT who have access to timely follow-up appointments and specialist investigations at appropriate intervals in accordance with NICE guidance.
Numerator – the number of requested appointments and specialist investigations for people with COAG, suspected COAG or with OHT.
Denominator - – the number of available appointments and specialist investigations for people with COAG, suspected COAG or with OHT.
b) Proportion of people with COAG, suspected COAG or with OHT, whose appointment has been cancelled, delayed or missed who have their clinical priority assessed.
Numerator – the number of people in the denominator with a clinical priority assessment.
Denominator – the number of people with COAG, suspected COAG or with OHT and a cancelled, delayed or missed appointment.

33. Quality statement 8 – Service capacity cont.
People diagnosed with COAG, suspected COAG or with OHT have access to timely follow-up appointments and specialist investigations at intervals in accordance with NICE guidance. Sufficient capacity is put in place to provide this service, and systems are developed to identify people needing clinical priority if appointments are cancelled, delayed or missed.
Quality measure
Process:
c) Proportion of people with COAG, suspected COAG or with OHT
whose cancelled, delayed or missed appointment is rescheduled
within an appropriate time interval.
c) Proportion of people with COAG, suspected COAG or with OHT whose cancelled, delayed or missed appointment is rescheduled within an appropriate time interval.
Numerator – the number of people in the denominator with a rescheduled appointment following a cancelled, delayed or missed appointment within an appropriate time interval.
Denominator – the number of people with COAG, suspected COAG or with OHT with a cancelled, delayed or missed appointment.
Description of what the quality statement means for each audience: Refer to the Glaucoma Quality Standard
Source clinical guideline references:
National Patient Safety Agency. Rapid Response Report. Preventing delay to follow up for patients with glaucoma (RR004); 2, 4 and 5.
NICE clinical guideline 85 recommendations and (key priorities for implementation) and recommendations and
Definitions: Refer to the Glaucoma Quality Standard for definitions of ‘timely follow up appointments’.

34. Quality statement 9 - Documentation
Healthcare professionals involved in the care of a person with COAG, suspected COAG or with OHT have appropriate documentation and records available at each clinical encounter in accordance with NICE guidance.
Quality measure
Process:
Proportion of people with chronic open angle glaucoma
(COAG), suspected COAG or with ocular hypertension (OHT)
whose documentation and records are available to healthcare
professionals at each clinical encounter.
Quality measure
Structure: Evidence of arrangements to ensure that healthcare professionals involved in a person’s care have appropriate documentation available at each clinical encounter in accordance with NICE guidance.
Process:
Proportion of people with chronic open angle glaucoma (COAG), suspected COAG or with ocular hypertension (OHT) whose documentation and records are available to healthcare professionals at each clinical encounter.
Numerator – the number of people in the denominator whose documentation and records are available to the healthcare professional(s) present.
Denominator – the number of people with COAG, suspected COAG or with OHT attending a clinic appointment.
Description of what the quality statement means for each audience: Refer to the Glaucoma Quality Standard
Source clinical guideline references: NICE clinical guideline 85 recommendation (key priority for implementation).
Definitions: Refer to the Glaucoma Quality Standard for definition of ‘appropriate documentation and records’.

35. Quality statement 10 - Surgery
People with COAG who are progressing to loss of vision despite treatment or who present with advanced visual loss are offered surgery with pharmacological augmentation (for example, MMC or 5FU) as indicated and information on the risks and benefits associated with surgery.
Quality measure
Process:
a) Proportion of people with COAG who are progressing to loss of
vision despite treatment or who present with advanced visual loss
who are offered surgery with pharmacological augmentation (for
example, MMC or 5FU) as indicated.
b) Proportion of people with COAG offered surgery because they
are progressing to loss of vision despite treatment or who present
with advanced visual loss, who receive information on the risks
and benefits associated with surgery.
Quality measure
Structure: Evidence of arrangements to ensure that all people with chronic open angle glaucoma (COAG) who are progressing to loss of vision despite treatment or who present with advanced visual loss are offered surgery with pharmacological augmentation (for example, mitomycin C [MMC] or 5-fluorouracil [5FU]; see definitions below) as indicated and information on the risks and benefits associated with surgery.
Process:
a) Proportion of people with COAG who are progressing to loss of vision despite treatment or who present with advanced visual loss who are offered surgery with pharmacological augmentation (for example, MMC or 5FU) as indicated.
Numerator – the number of people in the denominator offered surgery with pharmacological augmentation (for example, MMC or 5FU) as indicated.
Denominator – the number of people with COAG progressing to loss of vision despite treatment or who present with advanced visual loss.
b) Proportion of people with COAG offered surgery because they are progressing to loss of vision despite treatment or who present with advanced visual loss, who receive information on the risks and benefits associated with surgery.
Numerator – the number of people in the denominator who receive information on the risks and benefits associated with surgery.
Denominator – the number of people with COAG who are offered surgery because they are progressing to loss of vision despite treatment or who present with advanced visual loss.
Description of what the quality statement means for each audience: Refer to the Glaucoma Quality Standard
Source clinical guideline references: NICE clinical guideline 85 recommendation (key priority for implementation).
Definitions: Refer to the Glaucoma Quality Standard

36. Quality statement 11 - Information
People with COAG, suspected COAG or with OHT are given the opportunity to discuss their diagnosis, prognosis and management, and are provided with relevant and accessible information and advice at initial and subsequent visits in accordance with NICE guidance.
Quality measure
Process:
Proportion of people with COAG, suspected COAG or
with OHT who are given the opportunity to discuss their diagnosis,
prognosis and management and who are provided with relevant
and accessible information and advice at initial and subsequent
visits in accordance with NICE guidance.
Quality measure
Structure:
Evidence of arrangements to ensure that people with chronic open angle glaucoma (COAG), suspected COAG or with ocular hypertension (OHT) are given the opportunity to discuss their diagnosis, prognosis and management, and are provided with relevant and accessible information and advice at initial and subsequent visits in accordance with NICE guidance.
Process:
Proportion of people with COAG, suspected COAG or with OHT who are given the opportunity to discuss their diagnosis, prognosis and management and who are provided with relevant and accessible information and advice at initial and subsequent visits in accordance with NICE guidance.
Numerator – the number of people in the denominator given the opportunity to discuss their diagnosis, prognosis and management and provided with relevant and accessible information and advice at initial and subsequent visits in accordance with NICE guidance.
Denominator – the number of people with COAG, suspected COAG or with OHT.
Description of what the quality statement means for each audience: Refer to the Glaucoma Quality Standard
Source clinical guideline references: NICE clinical guideline 85 recommendation (key priority for implementation)
Definitions: Refer to the Glaucoma Quality Standard for definition of ‘relevant information’.
Equality and diversity considerations:
All information should be provided in an accessible format tailored to the needs of the individual. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People with COAG, suspected COAG or with OHT should have access to an interpreter or advocate if needed.

37. Quality statement 12 - Discharge
People with suspected COAG or with OHT who are not recommended for treatment and whose condition is considered stable are discharged from formal monitoring with a patient-held management plan.
Quality measure
Process:
Proportion of people with suspected COAG or with OHT
who are not recommended for treatment and whose condition is
considered stable who are discharged from formal monitoring with a
patient-held management plan.
Quality measure
Structure: Evidence of arrangements to ensure that all people with suspected chronic open angle glaucoma (COAG) or with ocular hypertension (OHT) who are not recommended for treatment and whose condition is considered stable are discharged from formal monitoring with a patient-held management plan.
Process:
Proportion of people with suspected COAG or with OHT who are not recommended for treatment and whose condition is considered stable who are discharged from formal monitoring with a patient-held management plan.
Numerator – the number of people in the denominator discharged from formal monitoring with a patient-held management plan.
Denominator – the number of people with suspected COAG or with OHT who are not recommended for treatment and whose condition is considered stable.
Description of what the quality statement means for each audience: Refer to the Glaucoma Quality Standard
Source clinical guideline references: NICE clinical guideline 85 recommendation NICE clinical guideline 85 recommendation
Definitions: Refer to the Glaucoma Quality Standard

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NOTES FOR PRESENTERS:
Additional information:
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