NICE published the Selective laser therapy recommended to treat glaucoma and ocular hypertension Guidance in January 2022.
The Royal College of Ophthalmologists provided a response to the NICE consultation on the new guidance and our comments and feedback were acknowledged by NICE. We outline the main areas that ophthalmologists need to be aware of.
The NICE guidance recommends much greater use of Selective Laser Therapy (SLT) treatment including first-line use of 360° SLT to treat Ocular Hypertension (OHT) with IOP more than 24mm Hg if patients have a risk of visual impairment within their lifetime and patients with Chronic Open Angle Glaucoma (COAG). This excludes patients with Pigment Dispersion syndrome in both groups of patients. This has implications for service delivery providers including changes in practice and discussions with patients regarding options for their treatment.
The recommendations in the NICE guidance will mean considerable service transformation for some eye units and impact on service capacity with the increase in the number of patients receiving SLT. Some units have already begun implementing the recommendations. The impact of COVID and backlogs, funding for training, clinics and equipment will need to be managed at a local level. Additionally, the cost of buying and maintaining a SLT machine was included in the cost effectiveness study conducted alongside the LiGHT trial. NICE predicted that investment in SLT, whilst incurring high upfront costs, would over time be cost effective
NICE recognised that any implementation of the guidance will take time and recommended a generic prostaglandin analogue should be offered to people “as interim treatment if they are waiting for an SLT procedure”. This is to ensure that individual patients continue to access and receive appropriate care and they are not overlooked when services are adapted to meet the new recommendations.
There are also important considerations as part of the transformation of services regarding training for ophthalmologists and the multidisciplinary team. In its response to RCOphth comments, NICE emphasised the importance of planned training and governance arrangements.
- ‘The committee also noted that healthcare professionals who provide 360° SLT should be given support and have relevant training on the suitability and safety of the procedure, including its benefits and risks. They should also be trained in discussing these points and patient consent with patients and their family members or carers.’
- ’The committee wanted to make clear that if 360° SLT is suitable for a person, that person should be referred to a consultant ophthalmologist. They also discussed the safety of the 360° SLT procedure and agreed that healthcare professionals should discuss with the responsible consultant ophthalmologist the decision to offer it and how it will be performed. This means that with support from a consultant ophthalmologist, healthcare professionals such as specialty doctors, associate specialists, specialist nurses, optometrists and allied health professionals can perform 360° SLT.’
The NICE guidance development group (NGDG) acknowledged that more staff might need to be trained over time to deliver SLT procedures. They also considered that there may be issues with job plans that may not allow trained staff to have sufficient sessions to deliver SLT. However, the NGDG noted that with the introduction of new recommendations, future planning could be done by trusts to include the number of SLT sessions needed to offer SLT as first line treatment. This planning can allow more trained staff to have sufficient time to deliver SLT.
The rationale for new recommendations mentions that healthcare professionals such as specialty doctors, associate specialists, specialist nurses, optometrists and allied health professionals can perform SLT with support from a consultant ophthalmologist. The NGDG also noted the importance of establishing a multidisciplinary team where the responsible consultant ophthalmologist could discuss and delegate SLT procedures to trained staff. This has been captured in the evidence review and rationale in the guideline.
The RCOphth believes there are reasonable safeguards in the guideline’s recommendations point 1.6.7 regarding governance on who prescribes the SLT treatment. We feel clinical leads and medical directors should be aware of these recommendations when implementing the guidelines.
View and access the guidance tools
People newly diagnosed with glaucoma and ocular hypertension (OHT) should initially be offered selective laser therapy (SLT) treatment rather than eye drops, according to an updated NICE guideline published today (Wednesday, 26 January)