Emergency / crisis support: /emergency
If eye drops are not being covered, monitoring investigations are hitting benefit limits, surgery is being disputed, or you are experiencing an acute pressure crisis — these are the steps.
Acute Angle-Closure Glaucoma: Eye Emergency
Acute angle-closure is characterised by sudden severe eye pain, nausea, vomiting, blurred vision, seeing halos around lights, and a very hard, red eye. IOP can rise rapidly to dangerous levels.
- This is an ophthalmic emergency. Go to the nearest emergency facility immediately or call an ambulance.
- Acute angle-closure glaucoma is a PMB emergency. Emergency treatment cannot be refused.
- Time to treatment matters — prolonged high IOP causes irreversible optic nerve damage within hours.
For any new sudden visual change — sudden loss of vision, sudden severe pain, sudden onset of black spots or flashing lights — seek emergency ophthalmic care.
Common Glaucoma Financial Crises
- CDL eye drops not being covered or charged to MSA
- OCT / visual field benefit limits exhausted mid-year
- SLT laser procedure not authorised
- Trabeculectomy or tube shunt dispute
- Specialist consultation benefit exhausted from frequent monitoring visits
If Eye Drops Are Not CDL-Funded
If prescribed glaucoma drops are being charged to the MSA rather than CDL:
- Confirm active CDL registration status with the scheme (request written confirmation for ICD-10 H40 Glaucoma)
- Request that the pharmacy reprocess the dispensing under CDL using the scheme's chronic medication authority code
- If prior dispensing was processed against MSA incorrectly, request reprocessing
If the specific drop prescribed is not on the CDL formulary: - Ask your ophthalmologist to submit a non-formulary (step therapy or therapeutic choice) motivation - The motivation should state that the prescribed preparation is clinically appropriate for this patient and that available formulary alternatives have been trialled and are inadequate or are contraindicated
If OCT or Visual Field Benefits Are Exhausted
Glaucoma requires annual OCT and regular visual field testing for life. If benefit limits are being exceeded mid-year:
Visual field test: Ask your scheme whether visual field testing for a CDL condition can be motivated as a CDL management test rather than an outpatient diagnostic investigation — some schemes authorise additional tests under the CDL management pathway.
OCT: Similarly, request CDL-motivated authorisation for annual OCT as part of the minimum standard of glaucoma monitoring.
If additional tests are declined, discuss with your ophthalmologist which test is most critical in the current clinical situation — often OCT and visual field tests alternate (one per 6-month visit) rather than both at every visit, which can halve the benefit consumption for a year.
In the longer term, plan selection matters: identify plans with more generous ophthalmological diagnostic benefit limits or plans where glaucoma monitoring tests are explicitly covered under CDL.
If SLT Was Declined
SLT is a well-evidenced, minimally invasive procedure for IOP reduction — now supported as primary therapy in international guidelines (European Glaucoma Society, AAO). If declined:
- Ask your ophthalmologist to submit a clinical motivation citing the LiGHT trial evidence and guideline endorsement for SLT in open-angle glaucoma
- Include current IOP readings, target IOP, and why SLT is preferred over or in addition to additional drops
- Request pre-authorisation review (most initial declines are administrative — incorrect procedure coding or wrong benefit category)
- Submit through internal appeals if declined on clinical grounds
If Surgical Pre-authorisation Is Disputed
For trabeculectomy or tube shunt procedures:
- Ask your ophthalmologist to submit a formal motivation: current IOP on maximum tolerated medical therapy, visual field loss progression rate, and clinical justification for surgery
- Request written authorisation from the scheme for the procedure, facility, and implant (if applicable) before confirming the surgery date
- Confirm the ophthalmologist's fee vs scheme rate; arrange gap cover if in place; negotiate with surgeon if shortfall is unexpectedly large
A scheme refusing surgery for progressive glaucoma on maximum medical therapy is in a very difficult clinical position — the procedure is the standard of care when drops fail. Escalate through the CMS if the internal appeal fails.
Triage Table
| Situation | Priority | Action |
|---|---|---|
| Acute angle-closure (severe pain + visual disturbance) | Emergency | Emergency facility immediately; PMB |
| Sudden vision loss | High | Emergency ophthalmic care |
| Eye drops not CDL-funded | High | CDL registration check; reprocessing |
| OCT/VF benefit exhausted | Medium | CDL motivation for additional tests; alternate test scheduling |
| SLT declined | Medium | Guideline-based motivation; appeal |
| Surgery disputed | High | Formal clinical motivation; appeal; CMS |
Escalation Contacts
Council for Medical Schemes (CMS): 0861 123 267 | www.medicalschemes.org.za South African Glaucoma Society: www.saglaucoma.co.za AURA Emergency: /emergency
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This page is general information about medical schemes. It is not medical advice: speak to a healthcare professional about your own treatment. Medical aid and gap cover advice is given by Eldon de Waal, a Supervised Representative of Approach Administration (FSP 23579).