ICO Guidelines for

Glaucoma Eye Care

International Council of Ophthalmology Guidelines for
Glaucoma Eye Care
The International Council of Ophthalmology (ICO) Guidelines for Glaucoma Eye Care have been
developed as a supportive and educational resource for ophthalmologists and eye care providers
worldwide. The goal is to improve the quality of eye care for patients and to reduce the risk of vision
loss from the most common forms of open and closed angle glaucoma around the world.

Core requirements for the appropriate care of open and closed angle glaucoma have been summarized,
and consider low and intermediate to high resource settings.

This is the first edition of the ICO Guidelines for Glaucoma Eye Care (February 2016). They are designed to
be a working document to be adapted for local use, and we hope that the Guidelines are easy to read and
translate.

2015 Task Force for Glaucoma Eye Care

Neeru Gupta, MD, PhD, MBA, Chairman

Tin Aung, MBBS, PhD
Nathan Congdon, MD
Tanuj Dada, MD
Fabian Lerner, MD
Sola Olawoye, MD
Serge Resnikoff, MD, PhD
Ningli Wang, MD, PhD
Richard Wormald, MD

Acknowledgements
We gratefully acknowledge Dr. Ivo Kocur, Medical Officer, Prevention of Blindness, World Health
Organization (WHO), Geneva, Switzerland, for his invaluable input and participation in the discussions
of the Task Force.

We sincerely thank Professor Hugh Taylor, ICO President, Melbourne, Australia, for many helpful
insights during the development of these Guidelines.

International Council of Ophthalmology | Guidelines for Glaucoma Eye Care

International Council of Ophthalmology | Guidelines for Glaucoma Eye Care
Table of Contents

Introduction 2

Initial Clinical Assessment of Glaucoma 4

Glaucoma Assessment and Equipment Needs 5

Glaucoma Assessment Checklist 6

Approach to Open Angle Glaucoma Care 10

Ongoing Open Angle Glaucoma Care 13

Approach to Closed Angle Glaucoma Care 15

Ongoing Care for Closed Angle Glaucoma 16

Indicators to Assess Glaucoma Care Programs 19

ICO Guidelines for Glaucoma Eye Care 20

International Council of Ophthalmology | Guidelines for Glaucoma Eye Care | Page 1

Introduction
Glaucoma is the leading cause of world blindness after cataracts. Glaucoma refers to a group of diseases,
in which optic nerve damage is the common pathology that leads to vision loss. The most common types
of glaucoma are open angle and closed angle forms. Worldwide, open angle and closed angle glaucoma
each account for about half of all glaucoma cases. Together, they are the major cause of irreversible vision
loss globally. The burden of each of these diseases varies considerably among racial and ethnic groups
worldwide. For example, in western countries, vision loss from open angle glaucoma is most common,
in contrast to East Asia, where vision loss from closed angle glaucoma is most common. Patients with
glaucoma are reported to have poorer quality of life, reduced levels of physical, emotional, and social
well-being, and utilize more health care resources.

High intraocular pressure (IOP) is a major risk factor for loss of sight from both open and closed angle
glaucoma, and the only one that is modifiable. The risk of blindness depends on the height of the
intraocular pressure, severity of disease, age of onset, and other determinants of susceptibility, such as
family history of glaucoma. Epidemiological studies and clinical trials have shown that optimal control
of IOP reduces the risk of optic nerve damage and slows disease progression. Lowering IOP is the only
intervention proven to prevent the loss of sight from glaucoma.

Glaucoma should be ruled out as part of every regular eye examination, since complaints of vision
loss may not be present. Differentiating open from closed angle glaucoma is essential from a
therapeutic standpoint, because each form of the disease has unique management considerations
and interventions. Once the correct diagnosis of open or closed angle glaucoma has been made,
appropriate steps can be taken through medications, laser, and microsurgery. This approach can
prevent severe vision loss and disability from sight threatening glaucoma.

In low resource settings, managing patients with glaucoma has unique challenges. Inability to pay,
treatment rejection, poor compliance, and lack of education and awareness, are all barriers to good
glaucoma care. Most patients are unaware of glaucoma disease, and by the time they present,
many have lost significant vision. Long distances from healthcare facilities, and insufficient medical
professionals and equipment, add to the difficulty in treating glaucoma. A diagnosis of open or closed
angle glaucoma requires medical and surgical interventions to prevent vision loss and to preserve
quality of life. Preventing glaucoma blindness in underserved regions requires heightened attention to
local educational needs, availability of expertise, and basic infrastructure requirements.

There is strong support to integrate glaucoma care within comprehensive eye care programs and to
consider rehabilitation aspects of care. Persistent efforts to support effective and accessible care for
glaucoma are needed.1

1. Universal Eye Health: A Global Action Plan 2014-2019, WHO, 2013 www.who.int/blindness/
actionplan/en/.

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Open Angle Glaucoma Closed Angle Glaucoma

In open angle glaucoma, there is characteristic In closed angle glaucoma, optic nerve damage
optic nerve damage and loss of visual function and vision loss may occur in the presence of an
in the presence of an open angle with no anatomical block of the anterior chamber angle
identifying pathology. The disease is chronic by the iris. This may lead to elevated intraocular
and progressive. Although elevated IOP is pressure and optic nerve damage. In acute
often associated with the disease, elevated angle closure glaucoma, the disease may be
IOP is not necessary to make the diagnosis. painful, needing emergency care. More often
Risk factors for the disease include elevated the disease is chronic, progressive, and without
intraocular pressure, increasing age, positive symptoms. Risk factors for the disease include
family history, racial background, myopia, thin racial background, increasing age, female
corneas, hypertension, and diabetes. Patients gender, positive family history, and hyperopia.
with elevated IOP or other risk factors should Patients with these risk factors should be
be followed regularly for the development of followed regularly for the development of
glaucoma. closed angle glaucoma.

Open Angle Closed Angle

Glaucomatous Optic Nerve Damage Elevated IOP
Elevated IOP Glaucomatous Optic Nerve Damage
Visual Field Damage Visual Field Damage

Most patients with open and closed angle forms of glaucoma are unaware they have sight-
threatening disease. Mass population screening is not currently recommended. However, all
patients presenting for eye care should be reviewed for glaucoma risk factors and undergo clinical
examination to rule out glaucoma. Patients with glaucoma should be told to alert brothers, sisters,
parents, sons, and daughters that they have a higher risk of developing disease, and that they also
need to be checked regularly for glaucoma. The ability to make an accurate diagnosis of glaucoma,
to determine whether it is an open or closed form, and to assess disease severity and stability, are
essential to glaucoma care strategies and blindness prevention.

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Initial Clinical Assessment of Glaucoma
History
Assessment for glaucoma includes asking about complaints that may relate to glaucoma such as vision
loss, pain, redness, and halos around lights. The onset, duration, location, and severity of symptoms
should be noted. All patients should be asked about family members with glaucoma, and a detailed
history should also be taken.

Table 1 - History Checklist

Chief Complaint
Age, Race, Occupation
Social History
Possibility of Pregnancy
Family History of Glaucoma
Past Eye Disease, Surgery, or Trauma
Corticosteroid Use
Eye Medications
Systemic Medications
Drug Allergies
Tobacco, Alcohol, Drug Use
Diabetes
Lung Disease
Heart Disease
Cerebrovascular Disease
Hypertension/Hypotension
Renal Stones
Migraine
Raynaud's Disease
Review of Systems

Initial Glaucoma Assessment

Evaluation for glaucoma is recommended as part of a comprehensive eye exam. The ability to diagnose
glaucoma in its open or closed angle forms, and to evaluate its severity, are critical to glaucoma care
approaches and the prevention of blindness. Core examination and equipment needs to diagnose and
monitor glaucoma patients are listed in Table 2.

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Table 2 - Glaucoma Assessment and Equipment Needs - International Recommendations

Optional Equipment
Minimal Equipment
Clinical Assessment (Intermediate /
(Low Resource Settings)
High Resource Settings)

Near reading card or

distance chart with 5 standard 3- or 4-meter visual acuity
Visual Acuity letters or symbols lane with high contrast
visual acuity chart
Pinhole
Trial frame and lenses Phoropter
Refraction
Retinoscope, Jackson cross-cylinder Autorefractor

Pupils Pen light or torch

Slit lamp biomicroscope

Anterior Segment Corneal pachymeter
Keratometer

Goldmann applanation tonometer

Portable handheld applanation Tonopen
Intraocular Pressure
tonometer Pneumotonometer
Schiotz tonometer

Anterior segment optical

Angle Slit lamp gonioscopy coherence tomography
Structures Goldmann, Zeiss/Posner goniolenses
Ultrasound biomicroscopy

Fundus photography
Direct ophthalmoscope Optic nerve image analyzers
Optic Nerve Confocal scanning laser
(dilated if angle open) Slit lamp biomicroscopy with hand
ophthalmoscopy
held 78 or 90 diopter lens Optical coherence tomography
Scanning laser polarimetry

Direct ophthalmoscope
Head mounted indirect
ophthalmoscope with
Fundus 12 and 30 diopter lenses
20 or 25 diopter lens
Slit lamp biomicroscopy with
60 and 90 diopter lenses
78 diopter lens

Manual perimetry or automated Frequency doubling technology

Visual Field
white on white perimetry Short wave automated perimetry

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Glaucoma Assessment Checklist
Visual Acuity Corneal Thickness
Vision should be tested (undilated), The thickness of the cornea is measured to
unaided, and with best correction help interpret IOP readings. Thick corneas
at distance and near. Central vision may be tend to overestimate the IOP reading, and
affected in advanced glaucoma. thin corneas tend to underestimate the
reading.
Refractive Error
The refractive error will help to understand Intraocular Pressure
the risk of open angle glaucoma (myopia) IOP should be measured in each eye
or closed angle glaucoma (hyperopia). before gonioscopy and before dilation.
Neutralizing the error is important to Recording the time of IOP measurement
assessing visual acuity and visual fields. is recommended to account for diurnal
variation.
Pupils
Pupils should be tested for reactivity and Anterior Segment
afferent pupillary defect. An afferent The anterior segment should be examined
defect may signal asymmetric moderate to in the undilated state and after dilation (if
advanced glaucoma. the angle is open). Look for anterior
chamber shallowing and peripheral depth,
Lids/Sclera/ Conjunctiva pseudoexfoliation, pigment dispersion,
Evidence of inflammation, redness, ocular inflammation and neovascularization, or
surface disease, or local pathology may other causes of glaucoma.
point to uncontrolled IOP due to acute or
chronic angle closure, or possible glaucoma
drug allergy, or other disease.

Cornea
The cornea should be examined for
edema, which may be seen in acute or
chronic high IOP. Note that IOP readings
are underestimated in the presence of
corneal edema. Corneal precipitates may
indicate inflammation.

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Glaucoma Assessment Checklist (contd)

Angle Structures
The angle should be examined for the
presence of iris contact with the trabecular
meshwork in a dark room setting. The
location and extent, and whether it is due to
appositional or synechial closure, should be
determined by indentation gonioscopy.
The presence of inflammation,
pseudoexfoliation, neovascularization, and
other pathology should be noted.
Open angle on gonioscopy
Iris
The iris should be examined for mobility
and irregularity, the presence of anterior
and posterior synechiae, and
pseudoexfoliation at the pupil margin.
Forward bowing, peripheral angle crowding,
and iris insertion should be noted in
addition to the presence of inflammation,
neovascularization, and other pathology.

Lens
The lens should be examined for
cataract, size, position, posterior synechiae,
pseudoexfoliation material, and evidence of
Closed angle on gonioscopy with no structures visible
inflammation.

Pseudoexfoliation deposits at the pupil margin Plateau iris with peripheral iris roll

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Glaucoma Assessment Checklist (contd)

Optic Nerve
The optic nerve should be evaluated for characteristic signs of glaucoma. The degree of optic
nerve damage helps to guide initial treatment goals.

Early optic nerve damage may include a cup 0.5, focal retinal nerve fiber layer defects, focal
rim thinning, vertical cupping, cup/disc asymmetry, focal excavation, disc hemorrhage, and
departure from the ISNT rule (rim thickest inferiorly, then superiorly, nasally and temporally).

Moderate to advanced optic nerve damage may include a large cup 0.7, diffuse retinal nerve
fiber defects, diffuse rim thinning, optic nerve excavation, acquired pit of the optic nerve, and
disc hemorrhage.

Retinal nerve fiber layer defect Thinning of the inferior rim

Disc hemorrhage at 5 oclock Advanced glaucoma with 0.9 vertical cup

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Glaucoma Assessment Checklist (contd)

Fundus
The posterior pole should be evaluated for the presence of diabetic retinopathy, macular
degeneration, and other retinal disorders. See the ICO Guidelines for Diabetic Eye Care at:
www.icoph.org/downloads/ICOGuidelinesforDiabeticEyeCare.pdf.

The Visual Field

Preserving visual function is the goal of all glaucoma management. The visual field is a measure
of visual function that is not captured by the visual acuity test. Visual field testing identifies,
locates, and quantifies the extent of field loss. The presence of visual field damage may indicate
moderate to advanced disease. Monitoring the visual field is important to determine disease
instability as seen below.

Progressive vision loss over time

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Approach to Open Angle Glaucoma Care
A diagnosis of open angle glaucoma requires medical and possible surgical intervention to prevent vision
loss and to preserve quality of life. Once a diagnosis of open angle glaucoma is made, patient education
should begin regarding the nature of the disease, the need to lower IOP, along with discussions of
treatment options. Patients should be informed of the need to alert first degree relatives for the need of
a glaucoma examination.

The financial, physical, social, emotional, and occupational burdens of glaucoma treatment options should be
carefully considered for each patient. Recommendations, risks, options, and consequences of no treatment,
should be discussed with all patients in language that is understandable to the patient or caregiver. Classifying
glaucoma disease as early, or moderate to advanced, can help to guide IOP treatment goals and approaches.
A simplified approach to initiating care in glaucoma patients is summarized below in Table 3.

Table 3 - Initiating Open Angle Glaucoma Care - International Recommendations

Glaucoma Suggested IOP

Findings Treatment Considerations
Severity Reduction
Optic Nerve Damage Medication or
Lower IOP
Early
25% Laser trabeculoplasty
Visual Field Loss

Medication or
Laser trabeculoplasty or
Optic Nerve Damage
Moderate/ Lower IOP Trabeculectomy Mitomycin C
+ or Tube ( cataract removal and
Advanced 25 50%
Visual Field Loss intraocular lens [IOL]) and/or
Cyclophotocoagulation
(or cryotherapy)

Medication and/or
End-stage Blind Eye Lower IOP
25 50% Cyclophotocoagulation
(Refractory
(or cryotherapy) and
glaucoma) Pain (If painful)
Rehabilitation Services

Low resource settings pose unique challenges depending on the region. Particular attention should be
given to compliance with treatments and the capacity of the patient to obtain and use medication.
If a patient cannot afford the cost of drugs, initial laser trabeculoplasty would be favored wherever
equipment and expertise are available. If resources to manage glaucoma are insufficient, referral
is indicated.

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Table 4 - Medicines for Glaucoma Care: International Recommendations

Essential Medicines Optional Medicines

Eye Drops (Low Resource Settings) (Intermediate /
High Resource Settings)

Anesthetic Tetracaine 0.5%

Fluorescein 1%
Diagnostic
Tropicamide 0.5%

Pupil Constricting Pilocarpine 2% or 4%

Atropine 0.1, 0.5, or 1%

Pupil Dilating
Homatropine or cyclopentolate

Anti-Inflammatory Prednisolone 0.5% or 1%

Ofloxacin 0.3%, gentamycin 0.3%

Anti-Infectives
or azithromycin 1.5%

Prostaglandin analogs
Intraocular Pressure Lowering Other beta blockers
Latanoprost 50g/mL
(Topical) Carbonic anhydrase inhibitors
Timolol 0.25% or 0.5%
Alpha agonists
Fixed combination drops

Intraocular Pressure Lowering Oral and IV acetazolamide Methazolamide

(Systemic) IV mannitol 10% or 20% Glycerol

See the 19th WHO Model List of Essential Medicines (April 2015), by going to:
www.who.int/medicines/publications/essentialmedicines/en/.

An ethical approach is indispensable to quality clinical care. Download the ICO Code of Ethics at:
www.icoph.org/downloads/icoethicalcode.pdf.

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Table 5 - Laser Trabeculoplasty for Glaucoma: International Recommendations

Treatment Argon Laser Trabeculoplasty Selective Laser Trabeculoplasty

Parameters (ALT) (SLT)
Frequency doubled Q-Switched
Laser Type Argon green or blue-green / Diode Laser
Nd: Yag Laser (532 nm)
Spot Size 50 microns (Argon) or 75 microns (diode) 400 microns

Power 300 to 1000 mW 0.5 to 2 mJ

Application Site TM junction non-pigmented/pigmented Trabecular meshwork (TM)

Goldmann gonioscopy lens

Handheld Lens Goldmann or SLT lens
or Ritch lens
Treated
180 360 degrees 180 360 degrees
Circumference

Number of Burns ~ 50 spots per 180 degrees ~ 50 spots per 180 degrees

Number of Sittings 1 or 2 1 or 2

Blanching at junction of anterior

Endpoint Bubble formation
non-pigmented and pigmented TM

Table 6 - Cyclophotocoagulation for Glaucoma: International Recommendations

Treatment
Transscleral Nd: YAG Laser Transscleral Diode Laser
Parameters
Laser Type Nd: YAG Laser Diode Laser

Power 4 to 7 J 1.0 to 2.5 W

Exposure Time 0.5 to 0.7 seconds 0.5 to 4.0 seconds

Application Site 1.0 to 2.0 mm from limbus 1.0 to 2.0 mm from limbus

Handheld Probe Transscleral contact Transscleral contact

Treated
180 360 degrees 180 360 degrees
Circumference

Number of Burns ~ 15 20 spots per 180 degrees ~ 12 20 spots per 180 degrees

Number of Sittings 1 or 2 1 or 2

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Ongoing Open Angle Glaucoma Care
Ongoing management of glaucoma depends on the ability to evaluate response to treatment, and to
detect disease progression and instability. Follow-up examinations are similar to the initial assessment
and should include history and clinical evaluation.

History: Ask about changes to general health and medications, visual changes, glaucoma drug
compliance, difficulty with drops, and possible side effects.

Clinical Assessment: Assess for changes in visual acuity or refractive error, IOP, new anterior
segment pathology, and changes to the angle anatomy, changes to the optic nerve, and changes
to the visual field.

Indicators of Unstable Open Angle Glaucoma

Elevated Intraocular Pressure
May be due to poor compliance, drug intolerance, or worsening glaucoma.

Progressive Optic Nerve Changes

Expanding nerve fiber layer defect, enlarging cup, new disc hemorrhage, and rim thinning.

Progressive inferior rim loss

Progressive visual field changes

Expanding visual field defect in size and depth, confirmed by repeat testing.

Progressive superior field loss

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Ongoing Open Angle Glaucoma Care
A rise in IOP, progressive optic nerve damage, or progressive visual field loss, signal the need for
additional medical or surgical intervention to prevent sight loss. A simplified approach to monitor and
follow patients with glaucoma is summarized below.

Table 7 - Ongoing Open Angle Glaucoma Care - International Recommendations

Classification Exam Findings Treatment Follow-up

Stable No Change to IOP and Optic Nerve

Continue ~ 4 months 1 year
Glaucoma and Visual Field

Increased IOP
Additional IOP 1 4 months
and/or
lowering needed (depending on
Unstable
Increased Optic Nerve Damage by 25% disease severity,
Glaucoma
and/or risk factors and
(Refer to Table 3) resources)
Increased Visual Field Damage

More frequent follow-up is suggested in the presence of advanced disease, multiple risk factors,
or progression within a short period. In low resource settings, compliance with treatment and the
capacity of the patient to obtain and use medication should be considered. Surgical options may be
favored earlier, wherever equipment and expertise are available. If resources to manage glaucoma
are insufficient, referral is indicated.

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Approach to Closed Angle Glaucoma Care
A diagnosis of closed angle glaucoma requires medical and surgical intervention to prevent vision loss.
If expertise and resources to manage glaucoma are insufficient, referral is indicated.

Once a diagnosis of closed angle glaucoma is made, patients should be educated regarding the nature
of the disease and required treatment to help prevent vision loss. The cause of angle closure will
determine the clinical care pathway, and as pupil block is the most common cause, laser iridotomy
is recommended as the first line treatment for all patients. A simplified approach to initiating care in
closed angle glaucoma patients is summarized below.

Acute angle closure with red eye Slit lamp beam shows very shallow
and forward iris bowing anterior chamber depth

Table 8 - Initiating Closed Angle Care - International Recommendations

Diagnosis Clinical Findings Essential Treatment Surgical Options

Constrict pupil and lower IOP

Acute or
Chronic Laser iridotomy (desirable) Lens extraction/IOL
Iris-trabecular contact
Closed Angle or Trabeculectomy
Iris bowing
(Pupil Block) Surgical iridectomy Mitomycin C
(laser to fellow eye)

Constrict pupil and lower IOP

Laser iridotomy (desirable)
Closed Angle Iris-trabecular contact Lens extraction/IOL
(Plateau Iris) or Surgical iridectomy
Flat Iris Trabeculectomy
(laser to fellow eye)
Mitomycin C
and
Laser iridoplasty

In addition to pupil block, progressive and irreversible angle closure may be due to plateau iris and
other causes. The chamber angle should be carefully reviewed after laser iridotomy to look for
other mechanisms of a closed angle needing treatment.

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Table 9 - Laser Iridotomy and Iridoplasty for Glaucoma: International Recommendations

Treatment Parameters Laser Iridotomy Laser Iridoplasty

Laser Type Q-Switched Nd: Yag Argon green or blue-green

Spot Size 200 500 microns
Power 2mJ to 8mJ 200 400 mW
Application Site Peripheral iris Peripheral iris
Goldmann gonioscopy lens
Handheld Lens Laser iridotomy lens
or Ritch lens
Treated Circumference 180 360 degrees
Number of Burns 20 40 spots per 180 degrees
Number of Sittings 1 1 or 2
Endpoint Full thickness iris opening Contraction burn

Ongoing Closed Angle Glaucoma Care

Ongoing management of angle closure glaucoma relies on the ability to evaluate response to treatment
and to detect disease progression and instability. Follow-up examinations are similar to the initial
assessment and should include history and clinical evaluation.

History: Ask about changes to general health and medications, visual changes, glaucoma drug
compliance, difficult with drops, and possible side effects.

Clinical Assessment: Assess for changes in visual acuity or refractive error, assess IOP, with
careful attention to the angle and changes to angle closure status, changes to the optic nerve,
and the visual field.

Indicators of Unstable Closed Angle Glaucoma

Persistent Angle Closure
Synechiae formation, failed iridotomy

Elevated Intraocular Pressure

Inadequate aqueous drainage

Progressive Optic Nerve Changes

Expanding nerve fiber layer defect, enlarging cup, new disc hemorrhage, rim thinning

Progressive Visual Field Changes

Expanding visual field defect in size and depth, confirmed by repeat testing

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Ongoing Closed Angle Glaucoma Care
Persistent angle closure with a rise in IOP, progressive optic nerve damage, or progressive visual field
loss, all signal the need for additional medical or surgical intervention to prevent sight loss. A simplified
approach to monitor and follow patients with glaucoma is summarized below.

Table 10 - Ongoing Closed Angle Glaucoma Care - International Recommendations

Classification Exam Findings Treatment Follow-up

~ 6 months 1 year
(depending on
Stable No Change to Angle,
Continue disease severity,
Glaucoma IOP, Optic Nerve, and Visual Field
risk factors, and
resources)

Persistent Angle Closure

and
Additional IOP 1 4 months
Increased IOP lowering needed (depending on
Unstable by 25% disease severity,
Glaucoma risk factors, and
Increased Optic Nerve Damage
(Refer to Table 11) resources)

Increased Visual Field Damage

More frequent follow-up is suggested in the presence of advanced disease, multiple risk factors,
or progression within a short period. In low resource settings, compliance with treatment and the
capacity of the patient to obtain and use medication should be considered. Surgical options may be
favored earlier, wherever equipment and expertise are available. If resources to manage glaucoma
are insufficient, referral is indicated.

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Unstable Closed Angle Glaucoma
Once closed angle glaucoma is deemed unstable, classifying the disease as early, or moderate to
advanced, helps to guide IOP treatment goals and approaches. The treatment options for a closed angle
differ from open angle care, and are summarized below.

Table 11 - Unstable Closed Angle Glaucoma - International Recommendations

Glaucoma Suggested
Findings Treatment Considerations
Severity IOP Reduction

Persistent Angle Closure

+
Lower IOP Medication
Early Optic Nerve Damage
25% Lens extraction/IOL

Visual Field Loss

Medication and/or
Trabeculectomy or tube (with
Persistent Angle Closure or without goniosynechiolysis,
+ cataract removal, and IOL)
Moderate / Optic Nerve Damage Lower IOP
Advanced 25 50% and/or
+
Cyclophotocoagulation
Visual Field Loss
(or cryotherapy)
Rehabilitation Services

Medication and/or
End-stage Blind Eye Lower IOP
25 50% Cyclophotocoagulation
(Refractory
(or cryotherapy)
glaucoma) Pain (If painful)
Rehabilitation Services

Intraocular pressure goals should be adjusted according to individual risk factors. Financial,
physical, and psychosocial burdens of each treatment option should also be considered. In low
resource settings, surgical options may be favored. End-stage disease treatment is similar to that
of open angle glaucoma. If resources or expertise to manage angle closure glaucoma are insufficient,
referral is indicated.

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Indicators to Assess Glaucoma Care Programs
a. Prevalence of glaucoma-related blindness and visual impairment.
b. Proportion of blindness and visual impairment due to glaucoma.
c. Last eye examination for glaucoma among known persons with glaucoma (males/females).
0 12 months ago

13 24 months ago

>24 months ago

Could be simplified as: 0-12 months ago, or >12 months ago

d. Number of patients who were examined for glaucoma during last year.
e. Number of patients who received laser trabeculoplasty, iridotomy, trabeculectomy, or tube
surgery during last year.
Define ratios such as:
f. Number of patients who received laser or trabeculectomy per million general population
per year (equivalent to cataract surgical rate [CSR]).

g. Number of patients who received laser, trabeculectomy, or tube treatments per number of
patients with glaucoma in a given area (hospital catchment area, health district, region, country).
Numerator: number of laser, trabeculectomy, or tube treatments during the last year

Denominator: number of patients with glaucoma (population x prevalence of glaucoma)

h. Number of patients who received laser, trabeculectomy, or tube treatments per number of
persons with vision-threatening glaucoma in a given area (hospital catchment area,
health district, region, country).
Numerator: number of laser, trabeculectomy, or tube treatments during the last year

Denominator: number of patients with vision-threatening glaucoma (population x

prevalence of glaucoma)

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ICO Guidelines for Glaucoma Eye Care
The ICO Guidelines for Glaucoma Eye Care were created as part of a new initiative to reduce worldwide
vision loss related to glaucoma. The ICO collected guidelines for glaucoma management from around
the world. View the collected guidelines at: www.icoph.org/enhancing_eyecare/glaucoma.html.

In addition to creating a consensus on technical guidelines, this resource will also be used to:
Stimulate improved training and continuing professional development to meet public needs.
Develop a framework to evaluate, stimulate, and to monitor relevant public health systems.

Design Credit
The ICO Guidelines for Glaucoma Eye Care were designed in collaboration with Marcelo Silles and
Yuri Markarov (photo, page 1), Medical Media, St. Michaels Hospital, Toronto, Canada.
Learn more at: www.stmichaelshospital.com.

Photo Credit
All photos that appear in the ICO Guidelines for Glaucoma Eye Care were provided by Prof. Neeru Gupta,
St. Michaels Hospital, Li Ka Shing Knowledge Institute, Ophthalmology & Vision Sciences, University of
Toronto, with the exception of the images on page 7, provided by Prof. Ningli Wang, Beijing Institute of
Ophthalmology. These may not be used for commercial purposes. If the photos are used, appropriate
credit must be given.

About the ICO

The ICO is composed of 140 national and subspecialty Member societies from around the globe. ICO
Member Societies are part of an international ophthalmic community working together to preserve
and restore vision. Learn more at: www.icoph.org.

The ICO welcomes any feedback, comments, or suggestions. Please email us at info@icoph.org.

ICO Headquarters:
San Francisco, California
United States
Fax: +1 (415) 409-8411
Email: info@icoph.org
Web: www.icoph.org

International Council of Ophthalmology | Guidelines for Glaucoma Eye Care | Page 20

Notes
Notes