The National Institute for Health and Clinical Excellence (NICE) issued new guidance yesterday on the management of glaucoma and ocular hypertension.

The recent guidance: Glaucoma: Diagnosis and management of chronic open angle glaucoma and ocular hypertension (NICE clinical guideline 85) makes recommendations for the diagnosis, treatment and care of adults at risk, or with a diagnosis, of chronic open-angle glaucoma, or who have a diagnosis of ocular hypertension.

The President of the Society for Clinical Ophthalmology, Professor Scott Fraser (Sunderland, UK) believes: “the guidelines are impressive in both their scope and depth. By sticking to high-quality evidence, rather than anecdote, they provide a blueprint for glaucoma care not only in this country but worldwide.”

NICE is an independent organisation that provides clinical guidance on the promotion of good health and the prevention and treatment of ill health on behalf of the UK Department of Health. Its official geographical scope is limited to England and Wales, but NICE recommendations tend to inform regulatory bodies and contribute to standards on an international scale.

The guidelines make recommendations for diagnostic and monitoring tests and Prof. Fraser commends this setting of gold standards. “Goldman tonometry and slit-lamp optic disc assessment,” are identified, Prof. Fraser explains, “as well as who should be looking after glaucoma patients and how often. Also emphasised more than once is the absolute key to glaucoma practice – the individualisation of patient care.”

Health Economists were involved throughout the development of the guidelines. In the past, NICE has been openly criticised in the popular press for the extent to which their decisions are informed by cost-effectiveness decisions, but Prof. Fraser remains a realist. He recognises the important of ensuring value for money in what he describes as a “cash-limited healthcare system.” Practitioners, he admits, have a tendency to forget that even the most simple interventions come at a cost.

In addition to offering healthcare professionals guidance on appropriate use of established tests and interventions, Prof. Fraser notes that they also highlight areas in which the profession is less well informed and help, “identify those areas where research is most needed.”

Prof. Fraser’s summarises the important take-home messages from the guidance as:

  • The acknowledgment of the importance of the ophthalmologist in the care of the glaucoma patient. “This doesn’t mean that all patients have to be seen by medical staff on all visits,” Prof. Fraser explains, “but it does mean that the Ophthalmologist takes ultimate responsibility for the monitoring and treatment of glaucoma sufferers.”

  • Recognition that the clinician has to have freedom to work around the guidelines. “Explicit guidelines on when to treat patients in various categories is useful,” Prof. Fraser agrees, but healthcare professionals also need to feel they have “freedom to vary form these guidelines when they feel it is necessary to do so.”

  • Guidance on the care of atypical patients. Recommendations for the management of patients who cannot be examined in the standard way is something that Prof. Fraser believes is rarely found in other guidelines.
  • Call for a national audit of trabeculectomy.

  • Recognition of the role of laser trabeculoplasty and the further research that is necessary in this area. “Some practitioners use laser trabeculoplasty as a ‘step’ in their management of patients”, Prof. Fraser explains, but “others disregard it completely.” He believes that high-quality evidence is needed to decide, “where, between these two extremes, its real role lies.”

  • Discussion of treatment cessation in those who have reached a certain age without developing glaucoma. This is an area that Prof. Fraser believes needs to be addressed, but seldom is.

  • Confirmation of the importance of the prostaglandin analogues and the continued role of beta-blockers.

While Prof. Fraser is loathe to criticise the guidelines, he would have preferred greater emphasis to have been made of the importance of continued gonioscopy. The role of the lens in glaucoma is becoming increasingly apparent, he Fraser explains. “Not infrequently, loss of intraocular pressure control is related to an unnoticed narrowing of angles; continued gonioscopy and estimation of increasing lens size is vital.” While the NICE guidelines do make mention of this, Prof. Fraser feels the issue warrants fuller consideration.

Prof. Fraser also recommends that any revision of the guidelines should discuss further the evidence supporting the recommendation for early surgery in advanced disease. “I am not sure there is real evidence for this,” he challenges. “As practitioners, we know that some patients respond extremely well to medications and that surgery is not justified, even in advanced disease.”

Professor Fraser’s comments can be accessed through the Society for Clinical Ophthalmology’s website.

The Society welcomes comments from eye care practitioners across all specialities.

The Society for Clinical Ophthalmology is a new, communications-focussed eye care society established in 2008. It is a not-for-profit organisation motivated by the goal of eradicating publication time lags by disseminating the latest developments in the world of eye care to a wide audience of practitioners and patients in a timely and accurate manner.
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