Ophthalmology · Full case

Glaucoma

NICE NG81POAG · OHTAcute closure = emergency

Silent sight-stealerChronic open-angle glaucoma (POAG) is usually asymptomatic until advanced — it damages the optic nerve and peripheral vision insidiously. It is a leading cause of irreversible blindness; most cases are detected on routine optometry, not by symptoms

IOP isn't everythingRaised intraocular pressure (IOP) is the major treatable risk factor, but glaucoma can occur at "normal" pressures (normal-tension) and high pressure without damage is ocular hypertension. Diagnosis rests on the triad of IOP, optic disc/nerve, and visual fields

Acute closure = emergencyAcute angle-closure glaucoma: sudden severe eye pain, red eye, blurred vision with haloes around lights, headache, nausea/vomiting, a fixed mid-dilated oval pupil and a hard eye — a same-day ophthalmic emergency to save sight

Prostaglandin first-lineFor POAG/OHT needing treatment, a topical prostaglandin analogue (e.g. latanoprost) is usually first-line — lowers IOP once daily. Selective laser trabeculoplasty (SLT) is now offered first-line in many cases (NICE NG81)

Risk factorsPOAG risk: raised IOP, increasing age, family history (1st-degree relative), African/Caribbean ethnicity, myopia, diabetes. Angle-closure risk: hypermetropia, older age, East Asian ethnicity, female sex, shallow anterior chamber, and pupil-dilating drugs/dim light

Watch the drugsDrugs with anticholinergic/sympathomimetic effects (some antidepressants, antihistamines, bronchodilators, anti-emetics, bladder antimuscarinics) can precipitate acute angle-closure in predisposed eyes by dilating the pupil — ask and warn

It runs in familiesFirst-degree relatives of POAG patients are at significantly higher risk — they should have regular optometric screening (often funded). Advising the patient to tell their family is part of good care

DVLA & adherenceGlaucoma affecting both eyes (or significant field loss) must be notified to the DVLA and may require a visual field standard for driving. Treatment is lifelong and silent — adherence to drops is the single biggest determinant of preserved vision

📋 Clinical Stem — Glaucoma

A 62-year-old man told by his optician he has "raised pressure and possible glaucoma", anxious about going blind, who has heard nothing since and isn't sure he needs the drops

Samuel Boateng, 62, attends after a routine eye test where the optician said he had "high pressure in the eyes and signs of early glaucoma" and referred him to the eye clinic. He has noticed no change in his vision and feels well. His father went blind "from his eyes" in old age. He is African-Caribbean, short-sighted, and has type 2 diabetes. He is worried about losing his sight but also unconvinced he needs treatment "for something that isn't bothering me", and he is a taxi driver concerned about his licence. He asks what glaucoma actually is, whether he'll go blind, and whether he really has to use eye drops for the rest of his life.

This stem tests the ability to: explain chronic open-angle glaucoma and ocular hypertension in plain language — a silent, usually asymptomatic disease detected on screening, diagnosed on the triad of intraocular pressure, optic disc and visual fields; recognise the patient's risk factors (age, family history, African-Caribbean ethnicity, myopia, diabetes); understand the GP's role (supporting the ophthalmology-led pathway, reinforcing adherence, recognising the acute angle-closure emergency, family screening advice and DVLA implications); address the adherence challenge of a silent disease and the "why treat something I can't feel" belief; and handle the patient's fear of blindness and his driving/licensing concerns. It also tests recognition of acute angle-closure glaucoma as a distinct, sight-threatening emergency.

Scenario A — Chronic open-angle glaucoma / OHT (this stem) Asymptomatic, found on optometry; risk factors present. Explain the disease and the triad; support ophthalmology-led treatment (prostaglandin drops/SLT); reinforce adherence; family screening; DVLA.

Scenario B — Acute angle-closure glaucoma (EMERGENCY) Sudden severe painful red eye, blurred vision with haloes, headache, nausea/vomiting, fixed mid-dilated pupil, hard eye. Same-day emergency ophthalmology; reduce IOP; do not delay.

Scenario C — Normal-tension glaucoma Glaucomatous disc/field changes with IOP in the "normal" range; still needs ophthalmology and IOP lowering; consider vascular factors.

Scenario D — Drug-precipitated angle-closure risk Predisposed (hypermetropic, shallow chamber) patient started on a pupil-dilating drug (some antidepressants/antihistamines/antimuscarinics) → acute closure. Recognise and warn.

Scenario E — Poor adherence / progressing disease Known POAG with worsening fields due to missed drops or side-effect intolerance. Explore barriers; simplify regimen; ophthalmology review; consider SLT/surgery.

Key variables to adapt for Open-angle (silent, chronic) vs angle-closure (acute emergency) vs normal-tension; risk factors (age, family history, ethnicity, myopia/hypermetropia, diabetes); the diagnostic triad (IOP, disc, fields); first-line treatment (prostaglandin drops / SLT); adherence to a silent disease; precipitating drugs; DVLA/occupation; family screening; pregnancy/comorbidity drug cautions (beta-blocker drops in asthma).

Steps:

Step 1

History — Symptoms vs Silence · Risk Factors · Exclude Acute Closure · ICE

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The history establishes which glaucoma you are dealing with — the silent chronic open-angle disease (Samuel's), or the acute angle-closure emergency — gathers the risk factors, and surfaces the beliefs that will determine whether the patient actually uses lifelong drops for a disease he cannot feel. The single safety question is whether any red, painful eye with haloes and vomiting is lurking, because that is a same-day sight emergency.

🎓 SCA framing — explain the silent disease, earn the adherence

"The tricky thing about this kind of glaucoma is that it causes no symptoms until late — which is exactly why we treat it before you'd ever notice anything. The drops protect the vision you still have. Can I explain how it works and what it means for you?"

Samuel doesn't feel ill and is unsure he needs treatment. The skill is to explain why a silent disease still needs lifelong treatment, in a way that makes adherence make sense to him — while taking his fear of blindness and his licence seriously.

1A — Symptoms, risk and the emergency screen

Question	Why it matters	Changes what?
🟢 OPEN QUESTION"Tell me what the optician said and what's worrying you about it."	Captures the referral, the patient's understanding and his agenda. Chronic open-angle glaucoma is typically found on routine optometry (raised IOP, suspicious disc, field defect) with no symptoms — which is why the optician, not the patient, raises it. Eliciting Samuel's fear (blindness, his licence) and his ambivalence about treatment shapes the whole consultation.In SCA: drawing out the "it isn't bothering me, why treat it" belief early is what lets you address adherence meaningfully.	Asymptomatic + optometry finding → chronic open-angle/OHT
🚩 Acute angle-closure screen"Have you ever had a sudden painful red eye, blurred vision with haloes around lights, headache or vomiting?"	The safety core. Acute angle-closure glaucoma is a different, sight-threatening emergency: sudden severe eye pain, red eye, blurred vision with haloes, frontal headache, nausea/vomiting, a fixed mid-dilated oval pupil and a hard, tender globe. It needs same-day emergency ophthalmology. Samuel has none — his is the chronic, silent type.	Acute closure features → same-day ophthalmic emergency.	Acute closure → emergency referral
Risk factors"Any family history of glaucoma or blindness? Are you short or long-sighted? Do you have diabetes?"	POAG risk rises with age, a first-degree family history, African/Caribbean ethnicity, myopia and diabetes — Samuel has several, which both supports the diagnosis and raises the stakes (and means his relatives should be screened). Angle-closure risk differs (hypermetropia, East Asian ethnicity, shallow chamber).	Multiple risk factors → higher prior probability; family screening advice.	Advise first-degree relatives to be screened
Visual symptoms & impact"Have you noticed any gaps or blurring in your side vision, or any difficulty driving or with steps?"	POAG damages peripheral vision first and is usually unnoticed until advanced; specific questions occasionally reveal early functional loss. Impact on driving/mobility matters for the DVLA conversation (Samuel is a taxi driver).	Field loss/impact → urgency; DVLA implications.	Field loss → DVLA notification
Medication & precipitants"What medicines do you take? Any antidepressants, antihistamines, inhalers, bladder or stomach tablets?"	Drugs with anticholinergic/sympathomimetic effects can precipitate acute angle-closure in predisposed (hypermetropic, shallow-chamber) eyes by dilating the pupil. Beta-blocker eye drops are contraindicated in asthma/heart block — relevant when treatment is chosen.	Predisposed eye + dilating drug → angle-closure risk (warn). Asthma → avoid beta-blocker drops.	Avoid precipitating drugs; tailor drop choice
Adherence barriers & beliefs"How do you feel about using drops every day, possibly for life, for something you can't feel?"	The central long-term challenge: adherence to lifelong drops for an asymptomatic disease. Beliefs ("it isn't bothering me"), dexterity, side effects, cost and forgetfulness all undermine adherence — and poor adherence is the main driver of avoidable progression. Surfacing this is essential.	Barriers identified → tailored support; reinforce why silent treatment matters.	Adherence support central to outcome

1B — Red flags

🚨

Red Flags — the eye that can't wait

Red flag	Why dangerous	Action
Acute angle-closure glaucoma — sudden painful red eye, haloes, blurred vision, headache, vomiting, fixed mid-dilated pupil, hard eye	Rapidly rising IOP threatens irreversible optic nerve damage and sight loss within hours.	Same-day emergency ophthalmology; do not delay; reduce IOP per ophthalmic advice
Rapidly progressing field loss / advanced glaucoma	Threatens central vision and independence; needs urgent ophthalmology escalation.	Urgent ophthalmology review
Drug-precipitated angle-closure in a predisposed eye	A new pupil-dilating drug can trigger acute closure — preventable and reversible if recognised.	Stop precipitant; emergency ophthalmology if acute; warn predisposed patients
Painful red eye of any cause with visual loss	Acute glaucoma, anterior uveitis, keratitis, scleritis — sight-threatening causes of the painful red eye.	Same-day ophthalmology assessment
Congenital glaucoma signs in an infant (watering, photophobia, enlarged/cloudy cornea)	Rare but sight- and eye-threatening; needs urgent specialist care.	Urgent paediatric ophthalmology
Non-adherence with progressive disease	The commonest avoidable cause of glaucomatous blindness.	Explore barriers; simplify regimen; ophthalmology; consider SLT/surgery

1C — ICE

💭 Ideas

"What's your understanding of what glaucoma is?"

Samuel may think glaucoma always causes symptoms, or conflate it with his father's blindness. Establishing his model lets you correct misconceptions, explain the silent nature, and connect treatment to protecting his remaining sight — the foundation for adherence.

😟 Concerns

"Is it the worry about going blind like your father — or the driving — that's on your mind most?"

His twin concerns — blindness and his taxi licence — are both legitimate. Addressing the fear honestly (most treated glaucoma does NOT lead to blindness) and being straight about the DVLA process respects him and improves engagement.

🎯 Expectations

"What were you hoping to get clear about today — and how do you feel about the drops?"

He wants to understand the diagnosis and may be looking for permission not to treat. Naming this lets you explain why treatment matters despite the absence of symptoms, and to make adherence a shared decision rather than an instruction.

1D — Psychosocial context

Glaucoma asks something difficult of patients: use eye drops every day, for life, for a condition that causes no symptoms — to prevent a loss they cannot yet perceive. That paradox, plus the emotional weight of a parent who went blind and the practical fear for a driving livelihood, sits at the heart of this consultation. The clinical task is less about prescribing (ophthalmology leads that) and more about understanding: making the silent disease real, framing the drops as protecting the sight he has, and being honest and supportive about blindness risk and the DVLA.

👁️ Fear of blindness

Honest reassurance: detected and treated glaucoma usually preserves useful vision for life; blindness mainly occurs when it's caught late or untreated.

"I understand the fear, especially with your dad. The good news is that because yours has been caught early and we treat it, most people keep good vision for the rest of their life. The danger is mainly when it's missed or left untreated."

💧 Why treat the symptomless

Reframe the drops as protecting existing vision, not curing a symptom.

"The damage glaucoma does can't be reversed — so the whole point is to protect the vision you have now, before you'd ever notice a problem. That's why the drops matter even though nothing feels wrong."

🚕 The driving conversation

Be straight about DVLA notification and the field standard, framed supportively.

"Because you drive for a living, we do need to be open about the DVLA — if glaucoma affects both eyes you have to tell them, and there's a vision standard. Many people with treated glaucoma keep driving; let's find out exactly where you stand."

👨‍👩‍👧 Family screening

Empower him to protect his relatives.

"Because glaucoma runs in families, it's worth telling your brothers, sisters and children to get their eyes checked — picking it up early in them is the best protection, just like it was for you."

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"Have you ever had a sudden painful red eye with haloes and vomiting?" — screens the acute emergency.

"The drops protect the vision you have now — the damage can't be reversed, so we treat before you'd notice anything." — earns adherence.

"Because it runs in families, your relatives should get their eyes checked." — family screening.

Deductions

Not distinguishing chronic open-angle from acute angle-closure
Not exploring/addressing adherence to a silent disease
Missing the DVLA/occupation implication
Failing to advise family screening

🔴 Red

Acute closure not screened; adherence not addressed; DVLA missed; family screening not advised; fear not acknowledged

🟠 Amber

POAG explained; risk factors noted; some reassurance; adherence/DVLA partly addressed; ICE partial

🟢 Green

Chronic vs acute distinguished; silent disease & adherence explained well; blindness fear addressed honestly; DVLA + family screening covered; risk factors recognised; ICE all three

Step 2

Triage — Acute Closure Emergency · Urgent Ophthalmology · Routine Pathway

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The triage hinge is acute angle-closure glaucoma (and the painful red eye with visual loss) — a same-day sight emergency — versus the chronic, optometry-detected open-angle disease that runs on a routine ophthalmology pathway.

🔴 Emergency

Same day

Sight-threatening

Acute angle-closure glaucomaPainful red eye, haloes, vomiting, fixed mid-dilated pupil, hard eye → emergency ophthalmology
Painful red eye + visual lossUveitis/keratitis/scleritis too → same-day assessment
Sudden severe visual lossEmergency eye assessment

🟠 Urgent

Soon

Ophthalmology

Advanced / rapidly progressing glaucomaUrgent ophthalmology
Very high IOP without symptomsPrompt referral
Non-adherence with progressionRe-engage; ophthalmology review

🟢 Routine

Standard pathway

Optometry → ophthalmology

POAG / OHT (asymptomatic)Ophthalmology-led diagnosis & treatment; GP supports
Glaucoma suspect on optometryReferral per local pathway
Stable treated glaucomaAdherence, monitoring, shared care

🎓 SCA Checkpoint — Step 2Tasks

Triage rationale

"Your type is the slow, silent kind that the eye clinic manages over time — not an emergency. But I want you to know the warning signs of the sudden, painful kind, which would need to be seen the same day."

Deductions

Treating a painful red eye with visual loss as routine
Not safety-netting the acute angle-closure warning signs

Step 3

Examination — Acuity · Pupil · Red Eye Signs · The Diagnostic Triad (specialist)

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In primary care, examination focuses on distinguishing the emergency (acute closure / painful red eye) from the chronic disease and on basic assessment — the definitive triad (IOP, optic disc, visual fields) is measured by optometry/ophthalmology with specialist equipment.

🩺 What the GP can assess

Check	Why
Visual acuity	Baseline; reduced acuity with a painful red eye → emergency.
Pupil	Fixed mid-dilated oval pupil → acute angle-closure; relative afferent defect → optic nerve.
Red eye signs	Ciliary flush, hazy cornea, hard tender globe → acute closure; distinguish from benign causes.
Fundoscopy (if able)	Increased optic disc cupping suggests glaucomatous damage (often better assessed by specialist).

🔬 The diagnostic triad (specialist)

Element	Detail
Intraocular pressure	Goldmann tonometry; the major treatable risk factor (but not the whole diagnosis).
Optic disc / nerve	Cupping, rim thinning, haemorrhages; OCT of the nerve fibre layer.
Visual fields	Perimetry — characteristic peripheral defects; also for DVLA standard.
Gonioscopy / pachymetry	Angle assessment (open vs closed); corneal thickness.

🎓 SCA Checkpoint — Step 3TasksGlobal Skills

Narration that scores

"I'll check your vision and look at your eyes — and the eye clinic will do the detailed tests: the pressure, a close look at the optic nerve, and a field test that maps your side vision."

Deductions

Not checking acuity/pupil in a possibly acute eye
Claiming to "diagnose" glaucoma on IOP alone

Step 4

Investigations — Specialist Diagnostics · Relevant Bloods · Drug Review

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Glaucoma is diagnosed and monitored with specialist ophthalmic investigations (the triad plus gonioscopy/OCT). The GP's "investigation" role is supportive — relevant comorbidity (diabetes), a medication review for precipitants and drop contraindications, and reinforcing attendance for monitoring.

🔬 Specialist diagnostics

Test	Role
Tonometry (IOP)	Treatable risk factor; monitored over time.
Optic disc imaging (OCT) / photos	Structural damage and progression.
Visual field perimetry	Functional loss; progression; DVLA standard.
Gonioscopy / pachymetry	Open vs closed angle; corneal thickness adjusts IOP interpretation.

🩺 The GP's contribution

Action	Why
Diabetes / vascular control	Diabetes is a risk factor and relevant to eye health; optimise.
Medication review	Identify pupil-dilating precipitants; check for beta-blocker drop contraindications (asthma, bradycardia, heart block).
Reinforce monitoring & adherence	Ensure attendance for IOP/field checks; support drop technique.
DVLA / occupational support	Advise on notification and the field standard.

🎓 SCA Checkpoint — Step 4Tasks

Key reasoning

"The eye clinic does the detailed tests; my job is to keep your diabetes well controlled, check none of your other medicines could harm the eye, and make sure you get the most from the drops and your check-ups."

Deductions

Ordering irrelevant tests; missing diabetes/medication review
Prescribing beta-blocker drops in asthma

Step 5

Diagnosis — POAG · OHT · Normal-Tension · Angle-Closure

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Name the type, because management and urgency differ completely — the chronic open-angle spectrum (treated to lower IOP and monitored) versus the acute angle-closure emergency.

Diagnosis	Discriminating features
Primary open-angle glaucoma (POAG)	Chronic, asymptomatic; raised IOP + glaucomatous disc/field changes; open angle. Treat & monitor (Samuel's likely diagnosis).
Ocular hypertension (OHT)	Raised IOP without optic nerve/field damage; risk of progression — treat per risk or monitor.
Normal-tension glaucoma	Glaucomatous damage with IOP in the "normal" range; still lower IOP; consider vascular factors.
Glaucoma suspect	Suspicious disc/borderline findings without definite damage — monitor.
🚩 Acute angle-closure glaucoma	Sudden painful red eye, haloes, vomiting, fixed mid-dilated pupil, hard eye — emergency.
Secondary glaucoma	From uveitis, trauma, steroids, neovascular (diabetes) etc. — treat the cause.

🚩 Two diseases sharing a name

"Glaucoma" spans a silent chronic disease that you treat for decades to protect vision, and an acute emergency that blinds within hours. The discipline is to know which you're dealing with and to safety-net the other. For Samuel, the diagnosis is the chronic open-angle spectrum (POAG/OHT) found on screening, in a high-risk man — needing ophthalmology-led IOP-lowering treatment, lifelong adherence, monitoring, family screening and DVLA attention — while he leaves knowing the warning signs of the acute, painful type.

🎓 SCA Checkpoint — Step 5Tasks

Explaining it plainly

"Yours is the slow type — the pressure in the eye is high and there are early signs on the optic nerve. We lower the pressure with drops to protect your vision, and the eye clinic keeps a close eye on it over time."

Deductions

Confusing the chronic and acute types
Implying high pressure alone = glaucoma (or that normal pressure excludes it)

Step 6

Referral — Emergency Eye Unit · Ophthalmology · Shared Care

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Glaucoma is ophthalmology-led. Referral is emergency for acute closure/painful red eye, routine via the optometry–ophthalmology pathway for POAG/OHT, and the GP supports shared-care monitoring and adherence.

Referral	Who / when	Urgency
🔴 Emergency eye unit	Acute angle-closure; painful red eye with visual loss; sudden visual loss.	Same day
Ophthalmology (routine)	POAG/OHT/glaucoma suspect detected on optometry — diagnosis, treatment decision and monitoring.	Routine pathway
Urgent ophthalmology	Advanced/progressing disease, very high IOP, or treatment failure.	Soon
Optometry	Case-finding, monitoring, and screening at-risk family members.	Routine
GP shared care	Adherence support, comorbidity, medication review, DVLA, family advice.	Ongoing

🎓 SCA Checkpoint — Step 6Tasks

Roles, clearly

"The eye clinic leads your treatment and monitoring. I'm here to support you between appointments — the drops, your diabetes, the driving question, and making sure your family get checked."

Deductions

Not referring an acute closure as an emergency
Not advising at-risk family screening

Step 7

Management — IOP-Lowering · Adherence · DVLA · Family · Safety-Net

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Treatment lowers intraocular pressure — topical prostaglandin analogues (or selective laser trabeculoplasty offered first-line in many cases), escalating through other drop classes and surgery as needed — but the GP's high-value contribution is adherence support, the DVLA/occupational conversation, family screening, comorbidity, and safety-netting the acute emergency.

7A — The plan

💧 Lowering the pressure (ophthalmology-led)

Element	Detail
First-line	Selective laser trabeculoplasty (SLT) offered first-line in many cases (NG81); or a topical prostaglandin analogue (e.g. latanoprost) once daily.
Other drop classes	Beta-blockers (avoid in asthma/heart block), alpha-agonists, carbonic anhydrase inhibitors — added/combined to reach target IOP.
Surgery	Trabeculectomy / drainage devices for refractory or advanced disease.
Acute angle-closure	Emergency IOP reduction then laser peripheral iridotomy (both eyes).

🤝 The GP's high-value work

Element	Detail
Adherence support	Explain why; drop technique; reminders; simplify regimen; address side effects/cost — the main determinant of outcome.
DVLA / occupation	Advise notification if both eyes affected/field loss; support a taxi driver through the standard.
Family screening	Advise first-degree relatives to have regular eye checks.
Comorbidity & drugs	Diabetes control; avoid precipitating drugs; check drop contraindications.
Safety-net	"Seek same-day help for a sudden painful red eye with haloes, headache or vomiting"; keep monitoring appointments.

🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills

A plan that scores

"Here's the plan: the eye clinic will start treatment to lower the pressure — drops or a quick laser — and monitor you. I'll help you stick with it, sort out the DVLA so you can keep driving where possible, check your diabetes and medicines, and you'll tell your family to get checked. Come straight in if you ever get a sudden painful red eye with haloes or vomiting."

Deductions

No adherence support for a silent lifelong treatment
Ignoring DVLA / occupation; no family screening advice
No acute angle-closure safety-net

"The optician said I've got high pressure in my eyes and the start of glaucoma, and sent a letter to the eye hospital. But my eyes feel completely fine — do I really need to be on drops for the rest of my life for something that isn't bothering me?"

Who you are

Samuel Boateng, 62, taxi driver, African-Caribbean, short-sighted, type 2 diabetic. A routine eye test found "high pressure and early glaucoma" and you were referred to the eye clinic. Your vision feels completely normal. Your father went blind in old age "from his eyes", which frightens you. You're torn: scared of blindness, but unconvinced you need lifelong drops for something symptomless, and very worried about your taxi licence. You want to understand what glaucoma is, whether you'll go blind, and whether you really must use drops forever.

Hidden concerns (reveal if explored)

Fear of blindness (main): your father's blindness haunts you. Honest reassurance that treated glaucoma usually keeps good vision really helps.

The licence: driving is your living; you're scared of losing it. You need straight talk about the DVLA.

Doubt about treatment: "why treat what I can't feel?" — if it's explained well (protecting existing sight), you accept it.

Clinical details if asked

No eye pain, no red eye, no haloes, no headache or vomiting — completely asymptomatic
No noticed change in vision; no gaps in side vision that you're aware of
Father went blind in old age (possibly glaucoma); African-Caribbean; myopic; type 2 diabetes
On metformin; no antidepressants/antihistamines/bladder tablets; no asthma
Drives a taxi for a living; worried about the licence
Haven't started any drops yet; waiting to hear from the eye clinic

Reactions at key moments

On the silent-disease explanation: "Ah — so it's about protecting what I've got." Accepts treatment once it makes sense.
On blindness: reassured by honest, hopeful framing.
On DVLA: anxious; reassured that many treated patients keep driving and you'll be supported through it.
On family: willing to tell relatives to get checked.
Challenge line: "If it's not bothering me and the optician's already dealing with it, why do I need to do anything?"

"Honestly, if my eyes feel fine and the hospital's going to see me anyway, why do I need to bother with drops every day for the rest of my life?"

Resolution: Samuel engages if the GP: (1) explains chronic open-angle glaucoma as a silent disease diagnosed on the triad (pressure, optic nerve, fields), and why treatment protects existing vision before symptoms appear; (2) recognises his risk factors and reassures honestly that treated glaucoma usually preserves useful sight; (3) addresses his adherence doubt constructively and supports drop use; (4) handles the DVLA/taxi-licence issue openly and supportively; (5) advises family screening and safety-nets the acute angle-closure warning signs. He stays ambivalent if simply told "use the drops", if his blindness fear and licence worry are not addressed, or if the silent-disease rationale is never explained.

🏥

Clinic Quick Reference

Glaucoma — Clinical Decision Framework

NICE NG81 · POAG/OHT vs acute closure · Adherence · DVLA

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🚦 1 — Which glaucoma?

Acute angle-closure (EMERGENCY)

Sudden painful red eye, haloes, blurred vision, headache, vomiting, fixed mid-dilated pupil, hard eye → same-day emergency ophthalmology.

Chronic open-angle / OHT

Silent; found on optometry; diagnosed on triad (IOP + disc + fields). Risk: age, family history, African-Caribbean, myopia, diabetes. Routine ophthalmology pathway.

💧 2 — Manage

Lower IOP (ophthalmology-led): SLT first-line in many (NG81) or prostaglandin drops; add other classes/surgery to reach target (avoid beta-blocker drops in asthma). GP role: adherence support (the key to outcome), DVLA notification + field standard, advise family screening, diabetes/medication review, avoid pupil-dilating precipitants, safety-net the acute emergency.

🎓

SCA Quick Reference

Glaucoma — Consultation Playbook

Silent disease · earn adherence · DVLA · family · spot the emergency

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🎯 The three pivots that pass this case

1 · Two diseases

Chronic open-angle is silent and treated for life; acute angle-closure (painful red eye, haloes, vomiting) is a same-day emergency — screen & safety-net it.

2 · Earn adherence

Explain the triad and why drops protect existing vision before symptoms — adherence to lifelong drops is the key to keeping sight.

3 · The wraparound

Honest blindness reassurance, DVLA/occupation, family screening, diabetes/drug review — the GP's high-value role.

⛔ Don't confuse silent open-angle with the acute angle-closure emergency · Don't equate raised IOP with the diagnosis (triad; normal-tension exists) · Don't ignore adherence to lifelong drops · Don't miss the DVLA/occupation duty or family-screening advice · Avoid beta-blocker drops in asthma; warn re pupil-dilating drugs

Glaucoma · GP Clinical Reasoning Framework v2 · NICE NG81 Glaucoma: diagnosis and management · NICE CKS Glaucoma · Royal College of Ophthalmologists · DVLA visual standards for driving

Chronic open-angle glaucoma is silent — diagnosed on the triad (IOP + optic disc + visual fields), not IOP alone; normal-tension glaucoma exists · Acute angle-closure (sudden painful red eye, haloes, vomiting, fixed mid-dilated pupil, hard eye) = same-day emergency · First-line IOP lowering: SLT (offered first-line in many cases) or prostaglandin drops; avoid beta-blocker drops in asthma · Risk: age, family history, African-Caribbean ethnicity, myopia, diabetes · GP role: adherence (key to outcome), DVLA, family screening, comorbidity, avoid precipitating drugs, safety-net

Teaching clinicians why each step matters — not just what to do · Always consult current NICE NG81/CKS and DVLA guidance · Clinical judgement takes precedence over any framework

Glaucoma

Red Flags — the eye that can't wait

👁️ Fear of blindness

💧 Why treat the symptomless

🚕 The driving conversation

👨‍👩‍👧 Family screening

Same day

Soon

Standard pathway

🚩 Two diseases sharing a name

🎭 Patient actor brief — click to practise

Who you are

Hidden concerns (reveal if explored)

Clinical details if asked

Reactions at key moments