What's New

Community Optometrists can now refer patients whom they suspect of having Ocular Hypertension or Glaucoma directly to the Hospital eye department.

GPs who are concerned that a patient has raised eye pressure or glaucoma should refer the patient to their Optometrist for a NHS or private sight test with an accompanying letter.

Glaucoma Care Pathway - Overview

Please click the relevant flowchart box to be taken directly to textual information.  


Red Flags

For chronic glaucoma:

  • Aged over 40
  • Very short sighted
  • Of African or Caribbean origin
  • Closely related to someone with chronic glaucoma


For acute glaucoma:

  • Symptoms of blurring are more sudden than gradual
  • Redness of the white of the eye
  • Pain in or around the eye
  • Long sighted

Normally asymptomatic until the very late stages when extensive visual field loss has occurred. The patient may report worsening or blurred peripheral vision.

Risk factors for chronic glaucoma include:

  • Family history- first degree relatives with a history of glaucoma.
  • Ethnicity- Afro Caribbean
  • Age- over 40 years
  • Myopia- being very short sighted increases the risk
  • Ocular hypertension- raised pressure within the eye increases the risk of glaucoma developing

Has a more sudden onset and can rapidly lead to irreversible sight loss.


  • Red eye
  • Pain in or around the eye
  • Rapid onset of Blurred or hazy vision
  • Fixed, mid-dilated pupil

Risk factors for acute glaucoma include:

  • Female
  • Hyperopia
  • Advanced cataract
Differential Diagnosis
When to Refer
  • Blurring of the eyes/noticing peripheral vision not as good
  • If not had a sight test in the last 2 years or if there is a family history of glaucoma and not had a sight test within the last 12 months
  • If a patient has a negative family history for glaucoma they should have a sight test every 2-3 years.
  • If a patient has a positive family history of glaucoma they should have a sight test every 12 months.
  • If a patient is overdue for a sight test they should be referred to their community Optometrist.
Community Eye Service


The Optometrist will complete a NHS or private sight test

The Optometrist will contact tonometry and/or refer the patient through the 'Repeat Readings' IOP pathway as required;

  • IOP measured using a Golmann or Perkins tonometer on two separate occasions

  • Any patients with IOP ≤ 21mmHg will be discharged
  • If IOP result is 22 - 31mmHg (if under 65), 24 -31mHg (if between 65 and 79 years), 25-31mmHg (if 80 years or over) or if there is a difference in IOP of ≥ 10 mmHg between the eyes then the patient will be referred to the hospital eye department.
  • If visual field test is inconsistent or not repeatable the patient will be discharged – GP will be notified if patient fails to attend repeat field test.

The optometrist will refer the patient through the 'Enhanced Case Findings' pathway which will include;

  • Disc assessment carried out with slit lamp / binocular indirect ophthalmoscopy
  • Goldmann Applanation Tonometry
  • Visual field carried out an automated visual field screener capable of producing a print out.

  • Direct referral to Hospital Eye Department for diagnosis and management
  • Inform GP
  • GP will be notified if patient fails to attend repeat field test.
Secondary Care Management
  • Monitor
  • Pharmocological Management – eye drops to reduce the pressure
  • Surgery may be advised if a trial of eye drops has failed to achieve target eye pressures, especially in younger people, or if patient has very high eye pressures.
  • Any ongoing follow up/treatment will be offered by the Acute Hospital.  
Ongoing Management

  • to provide general opthalmic services

  • Promote correct use of eye drops and check adherence
  • Monitor for allergy and other adverse effects of eye drops
  • Provide information, including about driving, and signpost to good information providers

Patient Resources

Please see the Community Resources and Patient & Carer Information & Leaflets sections.

Resources for Professionals

National Standards

Please see the National and NICE Guidance section.

Significant Variations for this Pathway

There are no significant variations from the national standards.

Other Online Resources


Please see the GP Education section.

Record Keeping and Audit

Joint audit of the pathway will be made quarterly with the CCG, PEG and Gloucestershire Hospital Trusts.


Pathway Leads





Ankur Trivedi

Clinical Director

PEG- Primary Eyecare Gloucestershire


Graham Mennie


Gloucestershire Clinical Commissioning Group


Ruth Hallett

Programme Director

Gloucestershire Clinical Commissioning Group


Reason for Pathway Selection

To accompany the launch of the Primary Eyecare Gloucestershire Glaucoma service.

Completion Date

May 2016

Review Date

April/May 2017