Sir,
The NICE guidelines for glaucoma1 gave key priorities for implementation in the management of glaucoma and ocular hypertension. It includes the minimum assessments and investigations. We assessed the adherence to NICE glaucoma guidelines in a university hospital. In addition, we assessed variation of investigations in relation to grade of doctor and final documentation of diagnosis.
The records of 50 consecutive new referrals for glaucoma, from September to December 2009, were reviewed. The records of the 25 patients who were diagnosed with glaucoma (including suspects) or ocular hypertension were further analysed. A pro forma of the NICE guidelines was created, which included age and sex of patient, investigations, documentation of diagnosis, and grade of doctor.
Thirty six percent of patients were seen by a glaucoma specialist. Overall, 48% were diagnosed with glaucoma, 16% were suspects, 16% had ocular hypertension, 4% had pigment dispersion syndrome, and 16% had no clear diagnosis. All patients had intraocular pressure measurement by Goldmann applanation tonometry, 64% had central corneal thickness measurements, and 76% had gonioscopy. One-third of patients diagnosed with glaucoma did not have a CCT measurement documented. Visual fields were performed in 96%, but only 32% were dilated for disc assessment and fundoscopy. The 68% of patients who were not dilated for fundoscopy were seen either by non-glaucoma consultants or trainees. Only 25% of those diagnosed with glaucoma had optic disc imaging with scanning laser polarimetry (GDx VCC).
Adherence to the NICE glaucoma guidelines is varied and depends on whether the patient is seen by a non-glaucoma or a glaucoma specialist. The key priorities highlighted by the guidelines need to be reinforced to improve adherence for a more adequate patient assessment. This sequentially can lead to fewer patients receiving avoidable follow-up appointments.
Goldmann IOP and VFs were well performed and documented. Gonioscopy, optic nerve imaging, pupillary dilation for optic nerve and fundus assessment, and CCT were poorly documented, which therefore requires attention. Although this consists of a small amount of data, it clearly reflects areas of weakness that may be demonstrated in other centres. This letter highlights possible areas for further training.
The authors declare no conflict of interest.
References
- UK National Institute of Health and Clinical Excellence Glaucoma: diagnosis and management of chronic open angle glaucoma and ocular hypertension 2009(available at http://www.nice.org.uk/CG85 ).