Managing glaucoma
Managing glaucoma
Last year, NICE updated its guidance on the diagnosis and management of glaucoma. Patients are generally only provided with medication if they have ocular hypertension with intraocular pressure (IOP) at or above 24mmHg and are at risk of visual impairment (defined as a severe reduction in vision that cannot be corrected with standard glasses or contact lenses and reduces a person’s ability to function) within their lifetime. However, the IOP treatment threshold is usually lower for patients with normal tension glaucoma (NTG) due to the increased risk of visual impairment.
Protocol
A generic prostaglandin analogue (PGA) should be offered to patients if they can’t have or don’t want to have selective trabeculoplasty (SLT), need interim treatment while waiting for SLT, or have had SLT and need additional treatment to reduce IOP
An alternative generic PGA should be offered to patients with an IOP of 24mmHg who do not tolerate the first product tried
A beta-blocker is the next option if neither PGA is tolerated
Further options include a non-generic PGA, carbonic anhydrase inhibitor, sympathomimetic, miotic or combination of treatments
For patients who are not experiencing a reduction in their IOP to under 24mmHg, a medicine from another therapeutic class (beta-blocker, carbonic anhydrase inhibitor or sympathomimetic) should be offered. Combinations may be needed to control IOP
Preservative-free eye drops should be offered to patients with an allergy to preservatives or those with clinically significant and symptomatic ocular surface disease, but only if they are at high risk of conversion to COAG
Glaucoma treatment is usually (but not always) lifelong, which can prove challenging as it is about preventing problems rather than solving symptoms. Getting into a good routine in terms of regular dosing can help, so suggest putting eye drops near the kettle or bathroom sink to act as a visual prompt tied in with a daily activity, or propose the use of alarms or reminders (e.g. on a mobile phone calendar).
Key facts
- Topical treatments are an important aspect of glaucoma management
- Checking eye drop instillation technique is an intervention that can make a significant difference, as can assessing whether the patient would benefit from a compliance aid
- Lifestyle advice and the provision of information has a part to play in glaucoma management.