RecommendationOffer stereoscopic slit lamp biomicroscopic examination of the optic nerve head to all people with COAG, who are suspected of having COAG or who have OHT at monitoring assessments.
Relative values of different outcomesThe GDG considered that finding optic disc abnormalities due to glaucoma using visualisation of morphological features of glaucomatous optic disc damage was the most important outcome, though finding an abnormal appearance of the disc is not useful in isolation from other tests.
Trade off between clinical benefits and harmsThe GDG considered bio-microscopic slit lamp examination to be the most important part of the assessment of the optic nerve. The GDG also considered that routinely using stereophotography with bio-microscopic slit lamp examination is not always practical in the clinical setting. Therefore, biomicroscopic slit lamp examination is recommended. The requirement for an optic disc image is made in a separate recommendation and is only required at baseline and when there is a suggestion of change. Stereophotography is useful for keeping a visual record of the optic disc at a given point in time but other imaging techniques can be used for this purpose.
Economic considerationsStereoscopic slit lamp biomicroscopy is less costly and it is the accepted clinical standard. Other methods (e.g. experts comparing serial stereo disc photographs) are more accurate but impractical for routine use in the NHS. There was no evidence that alternative disc imaging techniques result in better patient outcomes. It was the opinion of the GDG that this is the most accurate method among the practical ones. Furthermore the cost of the slit lamp could have been omitted from the economic analysis as this equipment is already adopted for the IOP measurement (see recommendation 4). Adding stereophotography to slit lamp examinations generates more costs with no evidence that provides any added value.
Quality of evidenceThere was a lack of evidence investigating the diagnostic accuracy of other optic disc imaging techniques against the reference standard.
The economic evidence has serious limitations and direct applicability.
Other considerationsPatient views. Patients should be alerted to possible consequences of having their pupils dilated. Dilatation for optic disc examination may be required which may affect a patient’s ability to drive afterwards. Obtaining accurate information outweighs the minor inconvenience caused by pupil dilatation. Requirement of a stereo photograph as well as slit lamp examination may impact on patient time at the clinic.
Alternative tests. Optical coherence tomography requires pupil dilatation. Scanning laser polarimetry and Heidelberg retina tomography usually do not require dilatation though this may be needed for certain patients. There may be a role for these technologies in detection of progressive change through sequential monitoring but evidence is as yet inadequate to support a recommendation in this regard.

From: 5, Monitoring of patients with ocular hypertension, chronic open angle glaucoma and suspected chronic open angle glaucoma

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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