RecommendationDiagnosis of OHT and suspected COAG and formulation of a management plan should be made by a suitably trained healthcare professional with:
  • a specialist qualification (when not working under the supervision of a consultant ophthalmologist) and
  • relevant experience.
Relative values of different outcomesAccurate measurement of visual field, optic nerve, IOP and the anterior chamber drainage angle are all considered as equally important outcomes because COAG is defined by all four. Further studies are needed to show agreement between different types of clinicians in the assessment of these parameters.
Trade off between clinical benefits and harmsPatients may receive their diagnosis sooner if evaluated in a community setting. Diagnosis of OHT and COAG suspects by staff other than consultant ophthalmologists may increase access to consultants’ care for patients requiring formal COAG diagnosis. Refer to section 1.8 for assumptions for OHT and COAG suspect.
Economic considerationsDiagnosis by healthcare professionals other than ophthalmologists could be cost-saving even when the cost of referrals to ophthalmologists is taken into account.
Quality of evidenceThe clinical evidence was of variable quality due to the following limitations: studies were not carried out in a systematic and controlled way, and there was the potential for selection bias as some patients were volunteers.
The economic evidence has serious limitations because the only study identified was not a full economic evaluation, the cost of false negatives were not estimated and the capital cost of necessary equipment for accredited optometrists was not included.
The economic evidence has partial applicability as it does not directly answer the clinical question.
Other considerationsAlthough not addressed as a clinical question the GDG noted that there is not always a high level of agreement between specialist ophthalmologists. However specialist ophthalmologists are considered to be the reference standard in this review. Therefore the reliability of our reference standard could be questionable.
Evidence is only available for optometrists, with no studies available for other non-medical healthcare professionals or non-ophthalmologist medical staff.
The GDG noted that the correct equipment to complete diagnostic assessments in keeping with the reference standards for tonometry, standard automated central thresholding perimetry and biomicroscopic slit lamp examination are required for healthcare professionals to perform diagnosis in a community setting and should be available.
Patient preference for assessment at hospital or in the community should be considered.

From: 10, Service Provision

Cover of Glaucoma
Glaucoma: Diagnosis and Management of Chronic Open Angle Glaucoma and Ocular Hypertension.
NICE Clinical Guidelines, No. 85.
National Collaborating Centre for Acute Care (UK).
Copyright © 2009, National Collaborating Centre for Acute Care.

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