Treatment for people with ocular hypertension (OHT) or suspected glaucoma

Treatment for people with OHT (ocular hypertension)

• do not offer treatment to people with OHT who are not at risk of visual impairment within their lifetime. Advise people to continue regular visits to their primary care eye professional, at clinically appropriate intervals.

Initial treatment for people with OHT

Offer 360 degrees selective laser trabeculoplasty (SLT) to people with newly diagnosed OHT with IOP of 24 mmHg or more (excluding cases associated with pigment dispersion syndrome) if they are at risk of visual impairment within their lifetime***. To help inform their decision, tell people:

• that having 360 degrees SLT can delay the need for eye drops and can reduce but does not remove the chance they will be needed at all
• how long it may take for their IOP to improve after the procedure
• about 360 degrees SLT-specific side effects and complications and how long they are likely to last
• that a second 360 degrees SLT procedure may be needed at a later date

Consider a second 360 degrees SLT for people with OHT if the effect of an initial successful SLT has subsequently reduced over time

Offer a generic prostaglandin analogue (PGA) to people with OHT with IOP of 24 mmHg or more if they are at risk of visual impairment ***within their lifetime and:

• they choose not to have 360 degrees SLT or
• 360 degrees SLT is not suitable (for example, because they have pigment dispersion syndrome) or
• they are waiting for 360 degrees SLT and need an interim treatment or
• they have had 360 degrees SLT but need additional treatment to reduce their IOP sufficiently to prevent the risk of visual impairment.
  
  Demonstrate correct eye drop installation technique and observe the person using the correct technique when eye drops are first prescribed.

***at the time of diagnosis of ocular hypertension (OHT), assess the risk of future visual impairment taking into account risk factors such as

• level of IOP
• CCT
• family history
• life expectancy

Ongoing treatment for people with OHT

• offer another pharmacological treatment to people with an IOP of 24 mmHg or more who cannot tolerate their current treatment. The first choice should be an alternative generic PGA, and if this is not tolerated, offer a beta-blocker. If neither of these options is tolerated, offer a non-generic PGA, carbonic anhydrase inhibitor, sympathomimetic, miotic or a combination of treatments
  
  
• offer a medicine from another therapeutic class (beta-blocker, carbonic anhydrase inhibitor or sympathomimetic) to people with an IOP of 24 mmHg or more whose current treatment is not reducing IOP sufficiently to prevent the risk of progression to sight loss. Topical medicines from different therapeutic classes may be needed at the same time to control IOP
  
  
• refer people to a consultant ophthalmologist to discuss other options if their IOP cannot be reduced sufficiently with 360 degrees SLT or pharmacological treatment or both to prevent the risk of progression to sight loss
  
  
• offer preservative-free eye drops 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 (chronic open angle glaucoma)

Treatment for people with suspected COAG

• do not offer treatment to people with suspected COAG and IOP less than 24 mmHg. Advise people to continue regular visits to their primary eye care professional, at clinically appropriate interval
• offer a generic prostaglandin analogue PGA to people with suspected COAG and IOP of 24 mmHg or more

Notes:

• the NICE committee agreed that the key outcome for adults with ocular hypertension (OHT) or chronic open angle glaucoma (COAG) was visual field progression that, in the long-term, could affect people's vision
  • intraocular pressure (IOP) was considered to be a relevant surrogate outcome because lowering IOP can prevent the risk of optic nerve damage and sight loss
  • high-quality evidence showed that there is no meaningful difference between 360 degrees selective laser trabeculoplasty (SLT) and eye drops in achieving a target IOP, health-related quality of life, risk of total adverse events, and treatment adherence
  • highlighted that there are rare complications associated with SLT
    • while rare events were not highlighted in the evidence, corneal failure is possible after SLT procedures
  • in people who have first-line treatment with eye drops compared with first-line 360 degrees SLT, more people used eye drops and more people have more than 1 eye drop medication at 12 months
  • cost-effectiveness evidence showed that first-line treatment with 360 degrees SLT was more effective and less costly compared with eye drops, with at least 90% probability of being the more cost-effective option
  • based on this evidence and their clinical experience, the committee recommended 360 degrees SLT as first-line treatment for people with newly diagnosed OHT or newly diagnosed COAG
    • recommendation excludes cases associated with pigment dispersion syndrome
      • was because there was no evidence on the use of 360 degrees SLT in people with pigment dispersion syndrome and the committee agreed that eye drop treatment is more suitable for those people

Reference:

• NICE (January 2022).Glaucoma: diagnosis and management