Stafford & Cannock GRR Service - Guidance for Accredited Optometrists (July 2015)

On 1st July 2015, the Stafford & surround CCG Glaucoma Referral Refinement scheme will go live. The NICE guidelines (2009) form the basis for these community service specifications.Your GRR accreditation will be used on your own patients as well as those referred in from unaccredited Optometrists.

As you will be aware, there are 2 levels of refinement, Test A & B.Please make sure you do read the guidance notes below for GRR pathway. All data following these tests should be entered on the Webstar IT module. The patient must also be registered with a GP practice from Stafford & Surrounds or Cannock Chase CCG areas to be eligible for this service.

TEST A guidance

  1. These are patients who have been referred in with IOP >21 mmHg in the absence of any confirmed signs of Glaucoma. When dealing with your own patient, GAT should be performed immediately after eye examination.Please note that GAT tonometry is the preferred gold standard to deliver this service but Perkins tonometry is also accepted.
  2. On receiving referral from unaccredited Optometrist, you/your practice must contact the patient within 48 hours to make an appointment. The patient should then be seen within 2 weeks
  3. There are 4 possible outcomes from this first repeat of pressures:
  • All patients with IOP >25 mmHg should be referred for OHT diagnosis without further IOP refinement
  • Other patients with a pressure of 22 - 25 need to proceed to Test B
  • Pressures which differ between the eyes by 5 mmHg or more should proceed to Test B
  • All other IOP results are within normal limits and the patient can be discharged. (When patient is discharged at this stage, please ensure you inform the referring Optometrist).

TEST B guidance

  1. The patient must be seen within 3 weeks of Test A where you will perform Test B. Do enquire about patient symptoms, family history of Glaucoma and measure VA. Then perform the following tests:
  • repeat GAT on a separate occasion
  • Repeat Fields (minimum 60 point central threshold test) Eg: Humphrey C24-2 (SITA FAST) or equivalent
  • Dilation of pupils & Volk optic disc assessment (stereo view) + document with photography
  • Van Herrick test (anterior angle assessment)
  1. After repeat GAT, if angles open, normal fields and disc appearance, there are 3 possible outcomes:
  • Any patients with IOP <=21mmHg should be discharged
  • If there is a difference in IOP of >=5mmHg between the eyes then consider referral to secondary care HES.
  • The following patients are referred to HES for OHT diagnosis:

-Age <65 yrs, IOP >21mmHg

-Age 65-79yrs, IOP > 24mmHg

-Age 80yrs+, IOP > 25mmHg

  1. If there are any suspect glaucomatous disc signs &/or occludeable anterior chamber angles &/or glaucomatous field defects, you must refer this patient into HES. Please note that the GRR pathway is IOP mediated so theoretically you should not be seeing many obvious glaucomatous discs. However, it is vital these are recognised when presented. Do remember that Glaucoma is a neuropathy, so disc appearance is a vital sign to ensure early diagnosis.
  1. Please be aware of College of Optometrists & AOP guidance regarding management of Glaucoma suspects in community. As per the joint guidance issued by College of Optometrists & Royal College of Ophthalmologists, practitioners may consider not referring patients at low risk of significant visual field loss in their lifetime:
  • Patients aged 80 years and over with measured IOPs <26mmHg with otherwise normal ocular examinations (normal discs, fields and van Herick).
  • Patients aged 65 and over with IOPs of <25mmHg and with otherwise normal ocular examinations (normal discs, fields and van Herick).

These groups do not qualify for treatment under current NICE guidance. Such

patients may be advised that they should be reviewed by a community

optometrist every 12 months.

  1. It is the responsibility of the accredited Optometrist to ensure that the Tonometer is calibrated and measurement has been appropriately taken. Remember to check for any corneal staining and manage appropriately. The field test result must be a reliable representation and may need repeating to achieve this. Where this is not possible, please make notes as to why this was the case.
  1. Do remember to give the patient a feedback questionnaire before they leave your practice after both Test A/B.
  1. Finally, welcome to the GRR scheme and hope you enjoy the clinical variation & challenges. This scheme plays a vital role in keeping patients out of secondary care setting and will be appreciated by your patients. You will be notified electronically about any updates but this information will also be available on the Staffordshire LOC website ( If you have any queries regarding the GRR pathway, do not hesitate to contact me on:

Thank you.

Irfan Razvi

Clinical Governance & Performance Lead for Glaucoma community services

SASPEC