General Debate: Glaucoma and community optometry

Glaucoma: overview What is glaucoma?

Glaucoma is a common eye condition that damages the optic nerve, which connects the eye to the brain. Damage to the optic nerve can lead to sight loss. There are three main types of glaucoma:

• primary glaucoma,
• secondary glaucoma caused by an underlying medical condition or trauma, and
• glaucoma in babies and children.

Glaucoma is usually caused by fluid building up in the front part of the eye, which increases the pressure inside the eye (known as the intraocular pressure). Glaucoma can also develop in people with normal intraocular pressure.

Primary open angle glaucoma affects around 2% of people in the UK above the age of 40. The charity Glaucoma UK explains anyone can develop glaucoma and it becomes more common with age. Other risk factors for glaucoma include a family history of glaucoma, being of African-Caribbean or east Asian origin, having long or short sight, diabetes, and having blood pressure problems.

What are the symptoms of glaucoma?

Glaucoma usually develops gradually and without symptoms in the early stages. This means many people only find out they have glaucoma during a routine eye test.

Glaucoma UK says people with glaucoma sight loss might notice misty or blurry patches in their vision, particularly if they close one eye. People with more advanced glaucoma may find daily activities such as reading and driving more difficult.

Very occasionally, glaucoma can develop suddenly. The NHS advises that this should be treated as a medical emergency.

Diagnosing and treating glaucoma

Glaucoma can be detected during a routine eye test at an opticians. The NHS says people should have a routine eye test every two years but people at higher risk may be advised to have more frequent tests.

If a test suggests glaucoma, the optician should refer the patient to a specialist eye doctor called an ophthalmologist who can confirm the diagnosis and advise on treatment.

Treatment for glaucoma can prevent vision from becoming worse but it cannot reverse vision loss.

There are different treatments for glaucoma, which are prescribed depending on what type of glaucoma the patient has. The most common type, primary open angle glaucoma, is usually treated with eye drops. Other treatments include surgery and laser treatment. Follow-up appointments are required to monitor glaucoma.

The National Institute for Health and Care Excellence (NICE) has published guidance on the diagnosis and management of glaucoma (last updated January 2022).

Community optometry

Optometry services in England are provided through high street opticians that hold contracts with the NHS and other locally commissioned enhanced primary care services, such as minor and urgent community eye care services. Patients may be referred from primary care to secondary care services, such as appointments with consultant ophthalmologists. There are different models of glaucoma pathway across the NHS, spanning primary and secondary care. In some areas, NHS commissioners have established glaucoma monitoring services in primary care, intended to alleviate pressure on secondary care.

Access to sight tests

NHS Digital publishes annual General Ophthalmic Services activity data. However, due to issues with the data at the time of writing this is unavailable.

Some people are entitled to a free NHS sight test. This includes:

• people diagnosed with diabetes or glaucoma,
• people over 40 with a mother, father, sibling or child diagnosed with glaucoma
• people who are at risk of glaucoma, as advised by an eye doctor.

People with a low income can receive help with NHS costs through the NHS Low Income Scheme.

People eligible for a free eye test may be eligible for a mobile eye test if they cannot attend an optician’s practice or have difficulty communicating their health needs due to a physical or mental illness or disability.

Those not eligible for a free sight test must cover the cost themselves. The Royal College of Optometrists has raised concerns about the impact of the rising cost of living on eye health.

Hospital activity and waiting lists

Data on hospital outpatient activity in England indicates that ophthalmology (treatment relating to the eye) is currently the busiest outpatient speciality in secondary care and that demand is growing.

NHS data shows that there were around 8.0 million ophthalmology outpatient appointments in England in 2022/23, making up around 8% of the total waiting list. This is up from 7.6 million outpatient appointments five years earlier in 2017/18.

As of February 2024, there were around 608,000 people on the hospital waiting list for ophthalmology treatment in England, including 14,500 people who had been waiting for over a year. The number waiting has risen from 424,000 in February 2019.

In February 2024, around 104,000 people started non-admitted ophthalmology treatment from the waiting list in England, and 59,600 started treatment as an admitted patient from the waiting list.

Improving access to glaucoma care

The Government has said NHS England’s transformation programme is looking at how more patients can be assessed, triaged and managed in the community to free up capacity in hospital eye services.

To support this aim, NHS England has published a standard clinical specification to enhance access to minor and urgent eye care. NHS England’s Getting It Right First Time (GIRFT) programme, which aims to improve the treatment and care of patients through clinically-led reviews of specialties, also has an ophthalmology workstream.

The NHS Long Term Workforce Plan, published in July 2023, notes that close working between primary and secondary care providers and new technology, such as digitally enabled image sharing, can help alleviate pressure in general practice and hospital eye services. The Government has also said the Ophthalmic Practitioner Training programme for hospital-based nurses, optometrist and orthoptists aims to upskill eye care professionals and includes glaucoma as a sub-specialty.

In February 2022, the NHS England published Delivery plan for tackling the COVID-19 backlog of elective care. It set out plans to expand community diagnostic centres (CDCs), increase surgical capacity through surgical hubs, improve patient pathways and access to specialist advice. The Royal College of Ophthalmologists published an article on what the plan means for NHS ophthalmology services.

In December 2023, a partnership of eye care stakeholders including the Royal National Institute of Blind People, the Association of Optometrists, and the Royal College of Ophthalmologists, published a report calling for a national plan for eye care (PDF). The group said there is a lack of awareness among the public of eye health and there is consensus across the sector that eye care services are inconsistently commissioned, with patient care often fragmented.

The report made twelve recommendations, including commissioning consistent universal NHS eye care services, including extended services, and establishing high-quality pathways of care. It also said the Government should build on the workforce plan by increasing the number of ophthalmology specialty training places in line with current and future patient need and expanding the wider workforce to increase diagnostic capacity.