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Glaucoma Assessment & Management Guidelines
INTRODUCTION:
The following guideline has been developed to safely manage a sub group of patients who require
glaucoma monitoring in collaboration with the departmental ophthalmologists.
The guidelines apply to all NDHB registered nursing staff that has completed the glaucoma
assessment and management competency.
All patients requiring glaucoma assessment will be managed according to the process outlined in
these assessment guidelines. Any variance will be documented in the patient’s treatment and
progress notes including rationale.
MANAGEMENT:
Patients suitable to be referred into a nurse’s clinic by consultant are as follows:


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Glaucoma suspect and Ocular hypertension who have clearly documented assessment and
management plans in place.
Stable glaucoma on medications for 6 monthly review
Therapeutic trial on medications (1-3 month follow up)
Stable glaucoma patients on no treatment having had Trabeculectomies with functioning
blebs.
Any other patients that the consultant requests a review in a nurse clinic
These patients will have:

Cup-disc ratio documented.

Target IOP recorded
The following are not suitable for referral:
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Patients with advanced glaucoma.
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Monocular patients.
PATIENT MANAGEMENT:
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Allow time to discuss the patients understanding of Glaucoma with patient and carer.
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Identify aids or methods for assisting patient with instillation of eye drops.
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Check with the patients understanding of the eye drop instructions.
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Supervise the patient with the instillation of their eye drops as required.
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Involve primary care team e.g. GPs, Optometrists, public health nurses as necessary.
NORTHLAND DISTRICT HEALTH BOARD
TITLE: Glaucoma Assessment & Management of Patients Guidelines
FIRST ISSUED: May 2011
CURRENT ISSUE : 2
REVISION DATE: June 2016
AUTHORED BY: Dr Dalziel
REVIEWED BY: Fiona Bamforth
AUTHORISED BY: N&M Workplace Competency Assurance Framework Governance Group
If printed, this protocol is valid only for the day of printing or for the duration of a specific patient’s admission
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INVESTIGATION REQUIRED:
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Visual acuity – distance.
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Identification of problems noted by patient.
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Applanation Tonometry (Goldmann).
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Pachymetry (Central Corneal Thickness).

Slit Lamp Examination:
1.
Cornea, anterior chamber, lens.
2.
Optic nerve and estimation of cup - disc ratio (CDR), optic disc size (vertical
diameter) & optic disc appearance.
3.
Macular.
Optic Disc Appearance:
Normal Optic disc
- Symmetry between two discs (in most places but not exclusive).
- Pink colour to neuroretinal rim.
- A cup which is usually centred in the upper temporal quadrant of the disc.
- Thicker rim inferiorly (ISNT rule applies)
- Intact nerve fibre layer.
Glaucomatous disc appearance
- Asymmetry between 2 discs (a difference in CDR ≥0.2).
- Thinning of the neural retinal rim.
- ISNT rule not followed
- Loss of the nerve fibre layer.
- Increase in pallor of the optic cup & neuroretinal rim.
 Humphrey visual field (24-2), at least yearly
 OCT/HRT as required.
Patients referred to the nurse will be monitored at least yearly by the ophthalmologist if the
patient’s condition remains stable.
Any changes from the patient’s condition will be discussed with an ophthalmologist.
These include:
 A decrease in visual acuity or reading vision of one or more lines.
 Patients with an intra ocular pressure greater than 4mmHg from the target IOP range.
 Any changes in the visual field analysis which suggests new visual field loss.
 Any patient who requests assessment by an Ophthalmologist.
NORTHLAND DISTRICT HEALTH BOARD
TITLE: Glaucoma Assessment & Management of Patients Guidelines
FIRST ISSUED: May 2011
CURRENT ISSUE : 2
REVISION DATE: June 2016
AUTHORED BY: Dr Dalziel
REVIEWED BY: Fiona Bamforth
AUTHORISED BY: N&M Workplace Competency Assurance Framework Governance Group
If printed, this protocol is valid only for the day of printing or for the duration of a specific patient’s admission
Page 2 of 3
5/05/2017
Eye drops for anaesthetic, staining and dilation.
The following standing order medications can be used for assessment

Gutt Oxbuprocaine 0.4%
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Gutt Fluorescein sodium 2%

Fluorescein Ophthalmic strips (Fluorets).
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Gutt Lidocaine Hydrochloride 4% & Fluorescein sodium 0.25%
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Gutt Tropicamide 1%
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Gutt Phenylephrine Hydrochloride BP 2.5%
Treatment
Arrange medication prescriptions with the ophthalmologist or House Surgeon for the patient if they
receive their glaucoma treatment prescription from the Eye Clinic. Otherwise request the patients
General Practitioner to provide prescriptions for the patient.
References:

European Glaucoma Society (2008). Terminology and Guidelines for Glaucoma (3rd ed.).
Savona, Italy: Dogma.

Glaucoma NZ - Professional Education Programme (online @
http://www.glaucoma.org.nz/)

Shaw, M., Lee, S. and Stollery, R. (2010). Ophthalmic Nursing (4th ed.). Chichester, West
Sussex, U.K: Wiley- Blackwell

Slight, C., Marsden, J. and Raynel, S. (2009). The impact of a glaucoma nurse specialist
role on glaucoma waiting lists. Nursing Praxis in New Zealand. 25 (1), 25-40.

South East Asia Glaucoma Interest Group (2008). Asia Pacific glaucoma guidelines (2nd
Edition). Sydney, Australia; Scientific Communications. Available from:
http://www.seagig.org/toc/APGG2_fullversionNMview.pdf
Acknowledgements:
Dr Wayne Birchall, Ophthalmologist, Whangarei Hospital.
Dr David Dalziel, Ophthalmologist, Whangarei Hospital.
Carol Slight, Nurse Practitioner-Glaucoma, Auckland District Health Board.
NORTHLAND DISTRICT HEALTH BOARD
TITLE: Glaucoma Assessment & Management of Patients Guidelines
FIRST ISSUED: May 2011
CURRENT ISSUE : 2
REVISION DATE: June 2016
AUTHORED BY: Dr Dalziel
REVIEWED BY: Fiona Bamforth
AUTHORISED BY: N&M Workplace Competency Assurance Framework Governance Group
If printed, this protocol is valid only for the day of printing or for the duration of a specific patient’s admission
Page 3 of 3
5/05/2017