01Purpose and principlesWhat the treatment does and how it fits into care.
Monitoring is a repeated decision about whether the current treatment is protecting the person's remaining vision. Pressure is an important modifiable risk factor, but it is a surrogate measure rather than the final outcome. The optic nerve and visual field may worsen despite apparently satisfactory clinic pressure, while an isolated poor-quality test can falsely suggest deterioration. Each review should distinguish true change, inadequate control and insufficient information.
Adherence is also a clinical finding that needs investigation. A person may understand the importance of treatment but be unable to squeeze a bottle, identify the correct eye, tolerate stinging or obtain repeat supplies. Another may deliberately reduce use because they believe symptomless disease cannot be serious. These situations need different solutions. Asking openly, watching the technique and checking the available support often provides more useful information than asking whether the patient is compliant.
Key points
- Judge glaucoma control through pressure, optic nerve structure and visual function, while considering treatment burden and the risk of lifetime sight loss.
- Check adherence, supply and observed instillation before declaring a pressure-lowering medicine ineffective.
- A measured pressure at target does not exclude progression; reproducible nerve or field deterioration should trigger a review of the target and treatment plan.
- NICE separates follow-up tables for treated ocular hypertension, suspected glaucoma and established chronic open-angle glaucoma.
- For established glaucoma with uncontrolled pressure, review in one to four months when progression is not detected, or one to two months when progression is suspected or present.
- For established glaucoma with controlled pressure, uncertain or confirmed progression prompts treatment review and reassessment in two to six months; urgent clinical circumstances require earlier action.
- Document the next due date, required tests, responsible service and route for chasing a delayed appointment; absence of symptoms is not evidence of stability.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
An unexpected elevation should prompt review of the measurement, timing, actual treatment use and possible secondary causes, followed by a management response proportionate to visual risk.
A consistent worsening field or optic nerve change can signal progression even if the pressure has reached the previous target; the target may need revision.
Unreliable fields, poor imaging, missed appointments or an incomplete baseline create uncertainty and should not be recorded as reassuring absence of progression.
Missed eyes, repeated bottle contamination, rapidly exhausted supplies or inability to read labels may reveal a delivery problem that can be improved with support or a different regimen.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Goldmann pressure and anterior segment reviewFirst step - Why
- Assess current pressure control and look for a change in ocular status.
- Interpretation and limitations
- Relate the result to the individual's target and earlier readings, checking relevant angle or surface findings; pressure alone cannot establish overall stability.
- 02
Repeatable field and optic nerve comparison - Why
- Detect clinically meaningful structural or functional deterioration over time.
- Interpretation and limitations
- Use consistent field strategy for an established defect and inspect test quality; compare actual serial findings rather than accepting a software progression label without review.
- 03
Observed eye-drop administration - Why
- Determine whether the prescribed treatment is being delivered effectively.
- Interpretation and limitations
- Ask the person to demonstrate their usual method with their own bottle when possible; a supportive demonstration can reveal a correctable problem without assuming intentional non-adherence.
- 04
Medication, supply and general health review - Why
- Identify adverse effects, interruptions, cognitive changes and new contraindications.
- Interpretation and limitations
- Reconcile prescriptions against bottles and actual use, including changes after surgery, admission or a new carer; a repeat prescription record does not prove every dose was administered.
04Treatment approachPreparation, options, escalation and aftercare.
01Routine reviewReassess control and set the next intervalFirst stepA person attends scheduled follow-up for ocular hypertension, suspected glaucoma or established glaucoma.+
- 1Confirm the diagnostic category, current treatment, functional concerns and any new ocular or systemic symptoms before interpreting the test results.
- 2Assess pressure control, the quality of structural and field data and the risk of future sight loss, separating no detected change from unresolved uncertainty.
- 3Use the appropriate NICE reassessment category and clinical judgement to set a due date, recording which service and tests are required and any earlier review after a treatment change.
02Delivery problemMake the regimen workablePressure control is inadequate or the person reports difficulty continuing the prescribed drops.+
- 1Ask specifically about missed doses, discomfort, bottle handling and supply in a non-judgemental way, and identify whether the barrier is practical, informational or preference based.
- 2Demonstrate suitable instillation, consider an administration aid, involve an agreed carer or pharmacist and simplify or change treatment when clinically appropriate.
- 3EscalationDocument the agreed change and arrange pressure reassessment, escalating promptly at the same time when the remaining vision makes delay unsafe.
03ProgressionReconsider the target and treatmentReliable repeated findings show worsening disease, or uncertainty and risk together require a closer assessment.+
- 1Confirm the pattern and rate of change against prior tests, examine for other causes of visual deterioration and review actual adherence and drug tolerance.
- 2Discuss a revised target and additional medication, laser or surgery with the glaucoma team, taking account of remaining visual reserve and the person's priorities.
- 3Arrange a specific short-interval review and explain the proposed intervention; do not continue the previous long surveillance interval solely because clinic pressure is within the usual range.
05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.
Latanoprost administration when prescribed for ongoing control
For latanoprost 50 micrograms/mL, deliver a single drop to each prescribed eye every evening and continue the agreed long-term course; resume at the next usual dose after a missed dose rather than doubling.Check that another bottle does not already contain latanoprost or a different prostaglandin analogue. Follow storage and in-use expiry instructions and avoid nozzle contact. Seek review for inflammation or visual change. Xalatan should not be used in pregnancy; during breastfeeding, agree an alternative medicine or cessation of breastfeeding with the treating team.
06Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- Treated ocular hypertension with baseline pressure at least 24 mmHg and currently normal disc and fields: uncontrolled pressure with no detected or uncertain conversion needs plan review in 1–4 months; controlled pressure with uncertain conversion is reassessed in 6–12 months, and controlled pressure without conversion in 18–24 months.
- Suspected chronic open-angle glaucoma: uncontrolled pressure with no detected or uncertain conversion leads to review in 1–4 months; if pressure is controlled, uncertain conversion leads to 6–12 months and no detected conversion to 12–18 months.
- Established chronic open-angle glaucoma with uncontrolled pressure: review the treatment plan and reassess in 1–4 months when progression is not detected, or 1–2 months when progression is uncertain or present.
- Established disease with controlled pressure: no detected progression allows 12–18 months for low clinical risk or 6–12 months for high risk; uncertain or definite progression requires treatment-plan review and reassessment in 2–6 months.
- These NICE ranges are applied with clinical judgement and the need to assess new treatment. Acute symptoms, threatened fixation, severe pressure elevation or other urgent circumstances can require assessment much sooner than the routine table interval.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
A target is a revisable clinical decision
Target pressure reflects disease stage, progression, life expectancy and the burden of additional treatment. It is not a universal population cut-off or a promise of safety. If credible deterioration continues at the target, reconsider how much further pressure reduction is needed and whether the target can be achieved acceptably.
Support effective drop delivery
Wash hands, check the right medicine and eye, and form a lower-lid pocket so one drop enters without the nozzle touching the eye or skin. Close the eyelids gently and use the product's punctal-occlusion advice. Separate different drops according to the relevant product instructions, and place ointment after drops when both are prescribed.
Treat the reason for missed doses
Reminder systems can help forgetting but do little for hand weakness, painful instillation or fear of side effects. A suitable bottle aid, a preservative change, an agreed carer arrangement or a discussion of laser may address the actual problem. Confirm that the person understands the revised plan by asking them to explain how they will use it.
A missed appointment has clinical meaning
A delayed visit lengthens the period during which deterioration may go undetected. Tell patients which service to contact if the appointment does not arrive and arrange risk-based follow-up of non-attendance. A stable previous measurement cannot justify an indefinite administrative delay, particularly when the eye has little remaining reserve.
Driving advice depends on licence and vision
DVLA administers licensing in England, Scotland and Wales; Northern Ireland uses DVA. Under current DVLA guidance, car and motorcycle drivers must report glaucoma affecting both eyes or their only seeing eye, and report when advised not to drive or when visual standards are not met. Bus, coach and lorry drivers have wider reporting requirements, including glaucoma in one eye. Anyone failing the applicable visual standards must stop driving.
Function and support belong in review
Ask about navigating steps, reading, glare, falls and confidence outside the home. The better-seeing eye and binocular function matter to daily life. Offer eye-clinic liaison and appropriate vision support where needed, alongside treatment decisions; do not wait for complete visual loss before discussing assistance.
Treatment withdrawal needs a planned test
NICE allows discussion of stopping treatment in selected low-risk ocular hypertension or suspected glaucoma with acceptable pressure. This is a shared clinical decision with reassessment in one to four months, not an unsupervised trial based on the absence of symptoms. Established glaucoma should not be treated as equivalent to this low-risk group.
08Common pitfallsFrequent interpretation and management errors.
- 01
Writing stable when the available field or imaging data are too poor to assess progression.
- 02
Using the same follow-up interval for treated ocular hypertension and established high-risk glaucoma.
- 03
Adding treatment without recognising that the original bottle is missing the eye or cannot be obtained.
- 04
Assuming a normal clinic pressure prevents further field loss and removes the need to review the target.
- 05
Telling a patient to await their routine appointment despite new pain, visual loss or significant systemic adverse effects.