IAPB Essential List: Glaucoma

The Essential Lists:

Glaucoma Essential list cover

Version: First Edition (March 2017)

Glaucoma is the leading cause of global irreversible blindness and the second most common cause of blindness worldwide. Congenital glaucoma is an important cause of childhood blindness.

What does this list contain?

This list contains recommendations for a range of equipment, instruments, consumables and pharmaceuticals required to provide quality glaucoma services. Efforts to to ensure that services are integrated, sustainable, excellent, equitable (ISEE), and available to all who need these, should be supported. Glaucoma care should be integrated within comprehensive eye care programmes, and linked to low vision and rehabilitation programmes and social support services. An example of an eye health team to provide comprehensive glaucoma care, includes personnel at primary, secondary and tertiary levels as depicted in the model.

Figure 1: This list is based on a three-tier model of care: Personnel at primary, secondary and tertiary level, able to refer appropriately for that level, both vertically for eye care services and horizontally to other service providers. All D or E items at a PRIM will be E at all SEC or TER. All D items at a SEC will be E at TER

How can quantities be calculated?

Recommendations for quantities of items have been calculated per million population per year based on a typical glaucoma unit/base hospital that performs opportunistic community glaucoma screening, medical treatment of outpatients diagnosed with glaucoma (1,000 patients per million population per month) and patients undergoing laser treatment.

Calculation of glaucoma surgery consumables was based on an average glaucoma surgical rate of 140 procedures per million population per year1.

Quantities need to be adjusted for different caseloads, since prevalence and incidence vary globally and the burden of disease also varies with changes in screening and referral practices. Additionally, factors such as surgical expertise and support to improve productivity will influence the workload.

Essential List Glaucoma Addendum

*** Items at a primary level should also be available at the secondary level , and items from both the primary and secondary level should be available at the tertiary level.

Description Standard List Category (S) or Locally Purchased (L) Essential (E) or Desirable (D) Quantity
Torch or other light e.g. ArcLight or Wilson Smart Loupe   E
For Relative Afferent Pupillary Defect
50
Materials suitable for providing information to the target audience about the risk factors and symptoms associated with glaucoma and the need for early detection, also compliance with management of the condition should accompany training   D
Material is developed and evaluated to ensure it is appropriate to target audience
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Visual Acuity Charts with letters and tumbling Es   E 5
Ophthalmoscope: Indirect or Direct e.g. ArcLight
For optic disc assessment 
  E 10
Tonometer: Non-Contact (Puff) or Contact e.g. Perkins or Tonopen
For intraocular pressure (IOP) assessment
  E 5
Perimeter: Frequency Doubling Technology (FDT) for vision field screening
FDT perimeter: cheaper, easier to use, good for screening
  D 1
Perimeter: Full threshold fields e.g. Standard Automated Perimeter (central thresholding test) Rarely used in the field / LMIC due to advanced glaucoma at diagnosis and lack of trained technicians   D 1
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Slit Lamp
To perform gonioscopy, Check for corneal oedema, depth of anterior chamber and secondary causes e.g. synechiae
  E 2
Slit Lamp Lenses - +90D and +60D or +78D
Disc/optic nerve assessment, with dilatation
  E 1 of each
Applanation Tonometer attached to Slit Lamp e.g. Goldmann
IOP measurement
  E 2
Spare tonometer heads   E 2
Gonioscopy: 3 Mirror Goldmann Gonio Lens or 4 mirror Zeiss or Sussman (D)
Peripheral anterior chamber configuration and depth assessment
  E 1 of coupled and one non-coupled
Pachymetry: Ultrasound or Optical
Central corneal thickness (CCT) measurement
  D 1
Fundus Camera: Stereoscope (preferably non-mydriatic)
Obtain optic nerve head image at diagnosis for baseline  documentation
  E 1
Optical Coherence Tomography (OCT): With or without Anterior Segment OCT Capability   D 1
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Applanation tonometry e.g. TonoPen / iCare/ Perkins hand-held tonometer
Intraocular pressure (IOP) may need to be recorded while the child is under general anaesthesia (GA). Pressures recorded while under GA are usually lower than those obtained in the clinic.
  E 1
Caliper
For measuring the corneal diameter (enlarged because of elevated IOP) Corneal diameter >12 mm in the first year of life is strongly suspicious of congenital glaucoma.
  E 1
Ultrasound pachymeter
Corneal swelling may occur
  E 1
Hand held slit lamp
The cornea may be oedematous and hazy. The anterior chamber may be deepened. Haab striae may be seen.
  D 1
Gonioscopy lens
The drainage angle needs to be examined. The iris and angle anatomy are frequently abnormal.
  E 1
Direct ophthalmoscope
Optic nerve examination
  E 1
A-scan ultrasound
To measure the axial length of the eye
  E 1
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Argon Green Laser   D 1
Selective Laser Trabeculoplasty   D 1
YAG laser   D 1
Diode Laser
•laser trabeculoplasty •iridotomy •transscleral cyclophoto- coagulation (TCP) (Less invasive) •endocyclopho- tocoagulation (ECP) (invasive) in combination with cataract surgery
  D 1
Iridotomy Laser Lens (any type)
Only applicable if you have an Argon, YAG or Diode laser
  E 1
ALT/SLT Laser Lens (any type)
Only applicable if you have an Argon, or SLT laser
  E 1
Hoskins laser suture lens (post trabx, post Baerveldt tube shunt)   D 1
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Complete Trabeculectomy Set     2
Non-toothed forceps eg. Moorfields   E  
Fine toothed forceps   E  
Fine needle holder   E  
Vannas scissors   E  
Spring scissors   E  
Paracetesis blade   E  
Speculum   E  
Diathermy   E  
Punch
Can do sclerostomy manually, but Kelly punch preferred
  D  
Full cataract set (MSICS or Phacoemulsification)
Ensure some toothed and non-toothed forceps, and paracentesis blade with trabeculectomy punch, diathermy, sponges for 5FU or MMC
  E 2
Micro invasive or minimally invasive glaucoma surgery (MIGS) - new procedures, undergoing testing: Trabectome, iStent, Xen Gel stent, CyPass micro-stent   Long term outcomes not known
May reduce challenges associated with eye drops such as cost, compliance and complications/ side effects.
 
Autoclavable Gonioprism
For Goniosyn- echialysis and MIGS eg. iStent e.g. Swan Jacob
  E  
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Goniotomy knife and surgical gonioscopic lens
Clear cornea needed
  E 1
Trabeculotomy probe
Can be performed in eyes with cloudy corneas
  E 1
Complete trabeculectomy set
Also needed for adult glaucoma
  E 1
Glaucoma Drainage Devices/implants/tube shunts   D As needed – keep 2 in stock
Cyclophotocoagulation   D When all else has failed
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Diagnostic Pharmaceuticals
Tetracycline Eye Ointment 1% - 5g (pack of 25)   E  
Paracetamol 500mg (1000 tabs)   E  
Fluorescein Strips
IOP
  E Box/100 - 600 boxes
Anaesthetic Drops e.g. benoxinate, amethocaine, tetracaine 0.5%, proparacaine
IOP
  E 15 ml – 2,000 bottles
Mydriatics eg. Tropicamide 0.5% and/or 1% Phenylephrine 2.5% and/or 5%
Pupillary dilation for optic nerve assessment (fundoscopy and/or photography)
  E 1% x 15 ml – 4,000 bottles
Hypochlorite Solution
Disinfection of Tonometer Head
  E 1 bottle
Methylcellulose or other coupling gel
Gonioscopy
  E 0.5% x 15 mls drops - 500 bottles
Medical Treatment: Intraocular Pressure (IOP) Lowering Pharmaceuticals
Prostaglandin Analogue (bimatoprost, latanoprost 50μg/mL, and travoprost 0.004%)
Increase uveoscleral outflow. Generally, the recommended first-line drugs: IOP lowering effect of 28–33%, once a day dosing, limited local side effects. However, they are expensive and can be difficult to obtain.
  E X 2.5 ml - 60,000 bottles
Beta-blockers consist of two main groups: non-selective (timolol 0.25%, levobunolol), and selective (betaxolol)
decrease aqueous production. Timolol is cheaper and quite effective (an IOP lowering effect of 20–30%), but it has systemic side effects: worsens obstructive pulmonary diseases, slows heart rate, lowers blood pressure. Timolol 0.5% is no more effective than 0.25% is, but is much more likely to cause side effects.
  E 10 mls - 15,000 bottles each (timolol 0.25% and betaxolol 0.25%)
Carbonic anhydrase inhibitors systemic (acetazolamide, methazolamide)
Decrease aqueous formation
  E 250 mg tablets 500/bottle – 200 bottles
Topical Carbonic Anhydrase Inhibitor. Dorzolamide 2%, brinzolamide 1%)
Decrease aqueous formation
  E X 10 ml - 15,000 bottles
Dorzolamide 2% / timolol 0.5% combination eye drops
Combination eye drops increase compliance and reduce toxicity to conjunctiva from preservatives
  D 40,000 bottles
Alpha-2 adrenergic agonists (apraclonidine, brimonidine) Brimonidine tartrate 0.1%
Decrease aqueous production and increase uveoscleral outflow. Also used prior to ALT, SLT and YAG laser to minimise post-laser IOP spike
  E X 10 ml - 20,000 bottles
IV acetazolamide 500 mgs provided as a sterile powder requiring reconstitution
For emergency use in acute glaucoma
  E Use as needed – keep 10 vials in stock
Osmotic diuretics eg: IV Mannitol 10%
For emergency use in acute glaucoma
    20% x 500 mls i.v. – 5 bags
Parasympathomimetics (pilocarpine, carbachol) increases aqueous outflow
Increases aqueous outflow through the trabecular meshwork by means of ciliary muscle contraction, and may open the drainage angle in angle-closure glaucoma by stimulating the iris sphincter muscle
E 2,000 bottles
Medical treatment for paediatric glaucoma: To be used with caution in this age group
These may be used as a temporary measure to lower IOP and assist with clearing of the cornea
  D As needed – can be obtained from adult pharmacy
Surgical Pharmaceuticals
Disinfectants and cleansers Povidone iodine aqueous 10% solution for skin (diluted to 5% for ocular surface)
For antiseptic preparation of surgical operating field and during removal of sutures in out-patient setting
  E 400 bottles
Local anaesthetic agents - lignocaine and bupivacaine injection Bupivacaine spinal 5mg/ml x 4 ml inj Lignocaine HCl 2% x 50 ml inj
For regional (periocular) anaesthesia
  E box/5 - 100
5-Flourouracil
Antimetabolite drugs use in trabeculectomy
  E 500mg/10 ml injection – 5,000
Mitomycin C (MMC) 5-Fluorouracil (where it is the only one available)
Antimetabolite drugs use in trabeculectomy and aqueous shunts
  E 40 mgs provided as a sterile powder requiring reconstitution – 100 bottles
Balanced salt solution
Irrigation of ocular surface following use of antimetabolites. Also used during intraocular surgery
  E 500 mls – 4,000 bottles
Subconjunctival or intracameral antibiotics eg. Cefuroxime
Prophylaxis against postoperative infection
  E 1.5 g inj i.v. – 100 bottles
Pilocarpine 1% or 2%
For PI (Argon PI or ALPI)
  E 500 bottles
Dexamethasone/Maxidex (5 ml) or Prednisolone 1%/Pred Forte (10 ml)
Post PI
  E 500 bottles
Antibiotic eye drops eg. gentamicin sulphate, tobramycin, ciprofloxacin, moxifloxacin
Prophylaxis against postoperative infection
  E 1,000 bottles
Tobramycin/dexamethasone or ciprofloxacin/dexamethasone
Combination eye drops increase compliance and reduce toxicity to conjunctiva from preservatives
  E 0.3%/0.1% x 5 mls or 7.5 mls drops or suspension– 1,000 bottles
Tobramycin/dexamethasone ointment   E 3.5 gm – 100 tubes
Atropine sulphate
Postoperative cycloplegia and pupillary dilation
  E 75 bottles
Intravitreal Bevacizumab (Avastin)
For neovascular glaucoma
  E 100mg/4ml injection – 15 bottles
Description Standard List Category or Locally Purchased (L) Essential (E) or Desirable (D) Quantity Required
Peribulbar needles and Subtenon’s cannulae
For administration of regional anaesthetic
  E 10/box – 50 boxes
10 O nylon and 6 or 8 O vicryl sutures (for trabeculectomy and glaucoma drainage devices) and 3 O supramid nylon monofilament stent suture for Baerveldt shunts   E 12/box – 15 boxes
30 gauge needles (for intravitreal and subconjunctival injections)   E 100/box – 5 boxes
Syringe on 27 gauge or 30 gauge anterior chamber (Rycroft) cannula   E as needed – at least 140 (1 per case)
Sponges for 5FU or MMC   E as many as needed
Drainage tubes – Ahmed, Baerveldt, Molteno
If surgical skills available
  E 25
Anterior chamber maintainer (eg. Lewicky cannula)   E as needed – keep 10 in stock
Bandage contact lenses--Large diameter (eg. 18-20 mm) soft contact lenses
For bleb leaks
  E as needed – keep 10 in stock
Freeze dried sclera or pericardium for human allograft (For coverage of tube in Ahmed valves Baerveldt tubes and during bleb revision/ repair of scleral defects caused by scleral melt. Can also use donor cornea or sclera from an Eye Bank if accessible)   E as needed – keep 2 boxes in stock
RESOURCES
Publication / Manual Published by Where available
Poster “What is wrong with my vision, and what can I do? Community Eye Health Journal Community Eye Health Journal
Glaucoma: diagnosis and management NICE Guidelines nice.org
ICO Guidelines for Glaucoma Eye Care ICO Guidelines ICO Glaucoma Guidelines
Glaucoma American Academy of Ophthalmology http://www.aao.org/eye-health/diseases/what-is-glaucoma
“Primary Open-Angle Glaucoma: Everyone’s Business” Community Eye Health Journal Volume 25 Issues 79 and 80 Community Eye Health Journal
The basics of good postoperative care after glaucoma surgery: Fatima Kyari, Mohammed M Abdull Community Eye Health Vol. 29 No. 94 2016 pp 29 - 31 Community Eye Health Journal
Glaucoma diagram Elektron Elektron
Considerations for Managing Hazardous Drugs, May 2016 Pharmacy Purchasing & Products (this journal is NOT open access) Pharmacy Purchasing & Products
Ensure the Safe Handling of Hazardous Drugs, March 2016 Pharmacy Purchasing & Products (this journal is NOT open access) Pharmacy Purchasing & Products
Mitomycin C: Indications for Use and Safe Practice in Ophthalmology American Society of Ophthalmic Registered Nurses American Society of Ophthalmic Registered Nurses
What is mitomycin C? Mobius mobiustherapeutics.com
Mitomycin C – safe handling, use and disposal (guidelines for operating theatre staff) ASORN American Society of Ophthalmic Registered Nurses

IAPB wishes to acknowledge and thank the following experts and organisations for their input and support in compiling this list:

  • Prof Stuart Graham – Professor Ophthalmology & Vision Science, Macquarie University, Australia
  • Dr Catherine Green – Royal Australian and New Zealand College of Ophthalmologists and Head of Glaucoma Unit, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
  • Dr Desirée Murray Lecturer in Ophthalmology, The University of the West Indies, St. Augustine Campus, Trinidad and Tobago
  • Dr Mohammed Abdull Ophthalmology department, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria
  • Dr Rѐnée du Toit – Independent Eye Health Consultant, South Africa
  • Dr Fatima Kyari – Clinical Ophthalmologist and IAPB Regional Chair West Africa, Nigeria
  • Philip Hoare – Procurement Manager, IAPB UK
International Council of Ophthalmology: Guidelines for Glaucoma Eye Care (2016)
IAPB also wishes to thank Elektron Technology for permission to adapt and use their Glaucoma Infographics

Screening for glaucoma by Fernando Yaacov Pena for the #EyeCareForAll Photo Competition held for World Sight Day

[1] Mansouri K, Medeiros FA, Weinreb RN. Global rates of glaucoma surgery. Graefe's Archive for Clinical and Experimental Ophthalmology. 2013;251(11):2609-15 (The average Glaucoma Surgical Rate (GSR) was 139.2 ± 113.1 (range, 2.9–500.0)

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