Urgent advice line: 01708 435 000 Ext. 6662

Please fill in the urgent eye care referral form [docx] 17KB and email it to bhrut.urgenteyecare@nhs.net

1. Primary open angle glaucoma
2. Acute angle closure glaucoma
3. Normal tension glaucoma
4. Bleb related infection
5. Pseudoexfoliation
6. Pigment dispersion syndrome
7. Neovascular glaucoma

Patients should be referred if the optometrist identifies one or more of the following:

• Optic disc signs consistent with glaucoma in either eye.
• Intraocular pressure (IOP) in either eye exceeds 22 mmHg (note referral in specific scenarios below).
• A visual field defect consistent with glaucoma is detected in either eye.
• A narrow anterior drainage angle on van Herrick testing consistent with significant risk of acute angle closure.
• Signs often associated with glaucoma (e.g. pigment dispersion or pseudoexfoliation).

1. Primary open angle glaucoma

Primary open angle glaucoma is a relatively common eye condition where the intraocular pressure (IOP) in the anterior chamber of the eye is chronically raised, with subsequent damage to the optic nerve and progressive peripheral visual fields loss.

Risk factors include:

• age >60 years,
• a positive family history in a first degree relative,
• myopia (short sightedness >3D),
• black, asian or hispanic,
• systemic hypertension, diabetes or sickle cell anaemia,
• thin corneas.

Refer patients routinely or ‘soon’ to the ophthalmology department for a review within the next four months.

Patients with disc haemorhages, an IOP 30-34 or with intermittent angle closure symptoms should be referred for review within two to four weeks.

2. Acute angle closure glaucoma

This is an ophthalmic emergency and the possibility of blindness should not be underestimated.

• The patient may not become symptomatic until the pressure rises above 50mmHg.
• Symptoms include severe eye pain, nausea and vomiting and reduced vision often due to corneal oedema.
• Signs may include a fixed, dilated pupil and an injected eye.
• Symptoms often start in dim lighting ie. in the evening.

If you suspect acute angle closure glaucoma, offer analgesia and antiemetics and lie the patient supine.

Refer urgently to the Emergency Eye Clinic by calling the urgent advice line: 01708 435 000 ext. 6662.

If out of hours then advise may be sought from Moorfields Eye Hospital main switchboard number 020 7253 3411 and ask to speak to the Emergency Department staff or Moorfields Direct A&E: 020 7521 4682.

3. Normal tension glaucoma and ocular hypertension

Normal tension glaucoma

Normal tension glaucoma occurs when the intraocular pressure is within normal range 12-22 mmHg however there are signs of visual field loss or damage to the optic nerve. Refer routinely to the glaucoma ophthalmology department for a review within the next 18 weeks.

Ocular hypertension

Ocular hypertension occurs when the IOP is above normal range (22mmHg), without any anterior segment abnormality, visual field loss or optic nerve cupping. 10% of ocular hypertensives will develop glaucoma over the next five years.

Refer routinely to the glaucoma service for a review in the next 18 weeks.

4. Bleb related infection

Bleb infection is a potentially blinding complication of trabeculectomy surgery as pathogens may enter the eye and cause an endophthalmitis.

The onset of infection from time of the trabeculectomy operation varies from months to years.

The patient presents with ocular redness, pain, photophobia and purulent discharge.

Signs may include mucopurulent infiltrate in the bleb, conjunctival injection, anterior chmamber cells, hypotony  and possible vitritis.

• If suspicious call the Emergency Eye clinic urgent advice line: 01708 435 000 ext. 6662.
• For out of hours please send of a conjunctival swab for cultures and sensitivities and start the patient on hourly Moxifloxacin day and night and advise in the urgent eye emergency referral form [docx] 17KB and email it to bhrut.urgenteyecare@nhs.net .
• (Moxifloxacin is contraindicated in children and patients with liver disease. Please use ciprofloxacin 750mg PO BD for 10 days instead).

5. Pseudoexfoliation

This is a systemic, age related condition that may cause a secondary glaucoma in about 30 per cent of patients. It manifests by some flaky fibrillar deposits that coat the anterior structures of the eye including the anterior lens capsule, iris, ciliary epithelium, corneal endothelium and trabecular meshwork.

Please refer routinely (within 18 weeks) to the glaucoma ophthalmology department unless there are signs of optic nerve dysfunction or an IOP >22 then refer for a review within a month.

6. Pigment dispersion syndrome

In this condition, pigmented cells in the back of the iris rub off against the fibres supporting the front of the lens. These pigmented cells can clog up the trabecular meshwork leading to increased intraocular pressure. It may progress to secondary glaucoma in 10-15% of cases.

Signs on examination include a pigmented trabecular meshwork on gonioscopy (Sampaolesi line), pigmented cells can be seen stuck to the back of the corneal endothelium (Krukenberg’s spindle), and iris transillumination defects.

Please refer routinely (within 18 weeks) to the glaucoma ophthalmology department unless there are signs of optic nerve dysfunction or an IOP >22 then refer for a review within a month.

7. Neovascular glaucoma/ iris rubeosis

This is a severe form of glaucoma caused by the proliferation of fibrovascular vessels on the iris and in the anterior chamber angle. This is usually in the context of retinal ischaemia such as central retinal vein occlusion or proliferative diabetic retinopathy.

This should be referred to the ophthalmology department for a review within two to four weeks.