75 Questions
What is the recommended method for intraocular pressure measurement before referral for further investigation of COAG and related conditions?
Goldmann-type applanation tonometry
Which of the following tests is NOT recommended for assessing peripheral anterior chamber configuration and depth?
Pachymetry
What is the purpose of pupil dilatation during fundus examination using stereoscopic slit lamp biomicroscopy?
To improve visualization of the optic nerve
What is the recommended approach for central visual field assessment before referral for further investigation of COAG and related conditions?
Standard automated perimetry with full threshold
What should NOT be the sole basis for referring a patient for further investigation of COAG and related conditions?
Intraocular pressure measurement using non-contact tonometry
What should a professional do if a person with IOP below 24 mmHg is referred to?
Advise them to continue regular visits to their primary eye care professional
What is recommended for people planning and providing eye care services?
Use a service model that includes Goldmann-type applanation tonometry before referral
What should be offered to diagnose COAG and related conditions?
All of the following tests: visual field assessment, optic nerve assessment, IOP measurement, and central corneal thickness measurement
What should be considered when assessing the risk of future visual impairment in people with ocular hypertension?
The level of IOP and central corneal thickness, among other risk factors
What should be repeated if necessary to establish severity at diagnosis?
Visual field assessment
What should be used if gonioscopy is not possible?
The van Herick peripheral anterior chamber depth assessment
What should be obtained at diagnosis for baseline documentation?
Either a stereoscopic optic nerve head image or an OCT image
When should a referral be made?
If there is optic nerve head damage, visual field defect, or IOP of 24 mmHg or more
What should be adopted to reduce the risk of transmitting infective agents?
Both professional and Department of Health and Social Care guidance
What should be considered for people with physical or learning disabilities?
The van Herick peripheral anterior chamber depth assessment
What records should be 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
What should be calibrated regularly according to the manufacturers' instructions?
All machines and measurement instruments
What should be taken into account when making decisions about management and treatment?
Cognitive and physical impairments
What should be checked before offering pharmacological treatment?
Relevant comorbidities or potential drug interactions
Who should not be offered treatment?
People with OHT not at risk of visual impairment within their lifetime
What should people be advised to do?
Continue regular visits to their primary eye care professional
What is offered to people with newly diagnosed OHT with IOP of 24 mmHg or more?
360° selective laser trabeculoplasty (SLT)
What is considered for people with OHT if the effect of an initial successful SLT has subsequently reduced over time?
A second 360° SLT
What is offered to people with OHT with IOP of 24 mmHg or more if they choose not to have 360° SLT?
Generic PGA
Why should correct eye drop installation technique be demonstrated and observed?
To ensure patient adherence
What should be offered to people with an IOP of 24 mmHg or more who cannot tolerate their current treatment?
An alternative generic PGA
What should be offered to people with an IOP of 24 mmHg or more whose current treatment is not reducing IOP sufficiently?
A medicine from another therapeutic class
When should people with suspected COAG and IOP less than 24 mmHg be offered treatment?
Only if they are at risk of visual impairment within their lifetime
What should be discussed with people with OHT or suspected COAG who have both a low risk of developing visual impairment within their lifetime and an acceptable IOP?
The benefits and risks of stopping treatment
What should be offered to people who present with advanced COAG and who are listed for glaucoma surgery?
Interim treatment with a generic PGA
What should be offered to people with advanced COAG?
Glaucoma surgery with pharmacological augmentation (MMC)
What should be offered to people with newly diagnosed COAG?
360° SLT
What should healthcare professionals discuss with patients about 360° SLT?
The possibility of needing eye drops in the future and the potential side effects of the procedure
When should preservative-free eye drops be offered?
To people who have an allergy to preservatives or people with clinically significant and symptomatic ocular surface disease, but only if they are at high risk of conversion to COAG
When should a second 360° SLT be considered for people with COAG?
If the effect of an initial successful SLT has subsequently reduced over time
What should be referred to a consultant ophthalmologist?
People whose IOP cannot be reduced sufficiently with 360° SLT or pharmacological treatment or both
What is the purpose of demonstrating correct eye drop installation technique?
To observe the patient's technique when eye drops are first prescribed
Why should healthcare professionals ask about adherence to treatment in people with COAG?
To check if the patient is taking the medication as prescribed
What should be given to people with advanced COAG who are listed for glaucoma surgery?
Information on the benefits and risks of surgery
What should healthcare professionals offer to people with COAG who are at risk of progressing to sight loss despite treatment with medicines from 2 therapeutic classes?
All of the above
What should healthcare professionals provide to people with COAG who are considering glaucoma surgery?
Information on the risks and benefits of the surgery
Why should healthcare professionals encourage people to continue with the same pharmacological treatment for COAG?
Unless the patient's IOP cannot be reduced sufficiently to prevent the risk of progression to sight loss
What should healthcare professionals offer to people with COAG who have satisfactory adherence to treatment and eye drop instillation technique but whose IOP has not been reduced sufficiently to prevent the risk of progression to sight loss?
A medicine from another therapeutic class
What should healthcare professionals consider for people with COAG who are waiting for an 360° SLT and need an interim treatment?
A generic PGA
Why should healthcare professionals offer 360° SLT to people with COAG who choose not to have a generic PGA?
Because the patient wants to avoid eye drops
What is the recommended treatment for people with COAG who cannot tolerate a pharmacological treatment?
A medicine from another therapeutic class or preservative-free eye drops
What should be considered after treatment with medicines from 2 therapeutic classes?
Glaucoma surgery with pharmacological augmentation
What is recommended for people with COAG whose IOP has not been reduced sufficiently to prevent the risk of progression to sight loss after glaucoma surgery?
Pharmacological treatment or topical medicines from different therapeutic classes
What is recommended for people with COAG who prefer not to have glaucoma surgery or for whom glaucoma surgery is not suitable?
Pharmacological treatment or topical medicines from different therapeutic classes
What tests are recommended at each assessment for people with COAG, people with suspected COAG, and people with OHT?
Goldmann applanation tonometry and anterior segment slit lamp examination
When is repeat gonioscopy recommended?
When clinically indicated
What is the recommended approach for visual field testing in people with COAG?
Using a central thresholding test or a supra-threshold test
What should be done when a change in optic nerve head status is detected by stereoscopic slit lamp biomicroscopy?
Obtain a new optic nerve head image
Why should pupils be dilated before stereoscopic slit lamp biomicroscopy or optic nerve head imaging?
To improve visualization of the optic nerve head
What should be repeated when clinically indicated in people with COAG?
Gonioscopy and visual field testing
What should be evaluated at each assessment for people with COAG, suspected COAG, and OHT?
Both the risk of conversion to COAG and the risk of sight loss
What should be asked about at each assessment for people with COAG, suspected COAG, and OHT?
Both the general health of the individual and factors affecting adherence to treatment
What is the recommended time to next assessment for people with treated OHT and a normal optic nerve head and visual field?
Between 18 months and 24 months
What should be used to decide when the next appointment should take place within the recommended interval?
Clinical judgement
What is included in uncertain conversion?
Having insufficient accurate information
What is the recommended time to next assessment for people with suspected COAG and uncertain conversion?
Between 1 month and 4 months
What should be assessed at each assessment for people with COAG?
Both the risk of COAG progression to sight loss and control of IOP
What is the recommended time to next assessment for people with COAG and uncertain progression?
Between 2 months and 6 months
What should be reviewed at each assessment for people with COAG and no progression detected?
Both the treatment plan and the impact of new treatments started
What is the recommended time to next assessment for people with COAG, no progression detected, and low clinical risk?
Between 12 months and 18 months
What is the reason for discharge back to primary care for people referred for OHT?
They do not need treatment
What should be given to people who have been assessed and discharged to primary care?
A discharge summary
Who should refer people to a consultant ophthalmologist for consideration of a definitive diagnosis and formulation of a management plan?
A suitably trained healthcare professional
What is essential for healthcare professionals involved in the diagnosis of OHT and suspected COAG?
All of the above
What is necessary for people with OHT, suspected COAG or COAG?
Monitoring and treatment from a trained healthcare professional
What should healthcare professionals involved in monitoring and treating OHT, suspected COAG and established COAG be trained to do?
All of the above
What is not sufficient for managing glaucoma and related conditions?
An independent or non-medical prescribing qualification
What should people be advised to take with them when attending future sight tests?
Their discharge summary
Where should a copy of the discharge summary be sent?
All of the above
What should be considered when managing OHT, suspected COAG and COAG?
All of the above
Study Notes
Referral and Diagnosis
- Before referral, offer all of the following tests:
- Central visual field assessment using standard automated perimetry
- Optic nerve assessment and fundus examination using stereoscopic slit lamp biomicroscopy
- Optical coherence tomography (OCT) or optic nerve head image
- Intraocular pressure (IOP) measurement using Goldmann-type applanation tonometry
- Peripheral anterior chamber configuration and depth assessments using gonioscopy or the van Herick test or OCT
- Do not base a decision to refer solely on IOP measurement using noncontact tonometry
- Consider repeating visual field assessment and IOP measurement on another occasion to confirm a visual field defect or IOP of 24 mmHg or more
Diagnosis
- To diagnose COAG and related conditions, offer all of the following tests:
- Visual field assessment using standard automated perimetry (central thresholding test)
- Optic nerve assessment and fundus examination using stereoscopic slit lamp biomicroscopy
- IOP measurement using Goldmann applanation tonometry
- Peripheral anterior chamber configuration and depth assessments using gonioscopy
- Central corneal thickness (CCT) measurement
- Adopt professional or Department of Health and Social Care guidance to reduce the risk of transmitting infective agents via contact tonometry or gonioscopy
Treatment
- For people with OHT, offer 360° selective laser trabeculoplasty (SLT) if they are at risk of visual impairment within their lifetime
- Offer a generic prostaglandin analogue (PGA) to people with OHT with IOP of 24 mmHg or more
- Consider a second 360° SLT for people with OHT if the effect of an initial successful SLT has subsequently reduced over time
- For people with COAG, offer 360° SLT or a generic PGA, and consider glaucoma surgery with pharmacological augmentation (MMC) as indicated
Ongoing Treatment
- Offer another pharmacological treatment to people with an IOP of 24 mmHg or more who cannot tolerate their current treatment
- Offer a medicine from another therapeutic class to people with an IOP of 24 mmHg or more whose current treatment is not reducing IOP sufficiently
- Refer people to a consultant ophthalmologist to discuss other options if their IOP cannot be reduced sufficiently with 360° SLT or pharmacological treatment or both
Stopping Treatment
- Discuss the benefits and risks of stopping treatment with people with OHT or suspected COAG who have both a low risk of developing visual impairment within their lifetime and an acceptable IOP
Reassessment
- At each assessment, offer the following tests:
- Goldmann applanation tonometry
- Anterior segment slit lamp examination with van Herick peripheral anterior chamber depth assessment
- Repeat visual field testing using standard automated perimetry (central thresholding test) or supra-threshold test
- Repeat assessment of the optic nerve head (stereoscopic slit lamp biomicroscopy or imaging)### Reassessment and Discharge
- Reassess people with COAG, suspected COAG, and OHT at each assessment to evaluate the risk of conversion to COAG and sight loss, and set a time for the next assessment.
- Consider general health, factors affecting adherence to treatment, cognitive impairment, and treatment side effects during reassessment.
Treated OHT with Normal Optic Nerve Head and Visual Field
- Reassess people with treated OHT (baseline IOP ≥ 24 mmHg) and normal optic nerve head and visual field at the most recent assessment based on clinical judgement.
- Use Table 1 to determine the time to the next assessment based on control of IOP and risk of conversion to COAG.
Suspected COAG
- Reassess people with suspected COAG based on clinical judgement, considering control of IOP and risk of conversion to COAG.
- Use Table 2 to determine the time to the next assessment.
Confirmed COAG
- Reassess people with COAG based on clinical judgement, considering the risk of COAG progression to sight loss.
- Use Table 3 to determine the time to the next assessment.
Discharge to Primary Care
- Discharge people back to primary eye care services if they were referred for OHT but do not need treatment or if they were referred for suspected COAG but it is no longer suspected.
- Provide a discharge summary to people being discharged, and send a copy to their GP and primary eye care professional with patient consent.
Organisation of Care
- Refer people to a consultant ophthalmologist for a definitive diagnosis and management plan if they have suspected optic nerve damage or repeatable visual field defect, or if SLT treatment is suitable.
- Diagnosis and management of OHT and suspected COAG should be made by a suitably trained healthcare professional with a specialist qualification and relevant experience.
- Healthcare professionals involved in diagnosis and management should be trained in case detection and referral refinement, and be able to perform and interpret relevant clinical tests and assessments.
- Monitoring and treatment of OHT, suspected COAG, and COAG should be done by a trained healthcare professional with a specialist qualification, relevant experience, and ability to detect changes in clinical status.
- Healthcare professionals involved in monitoring and treating OHT, suspected COAG, and COAG should be trained to make management decisions on risk factors, coexisting pathology, and risk of sight loss.
This quiz covers the necessary tests to diagnose and investigate glaucoma and related conditions. It includes central visual field assessment, optic nerve assessment, fundus examination, and intraocular pressure measurement. Test your knowledge of these essential diagnostic steps.
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