BACKGROUND: To determine the stage of primary open angle glaucoma at presentation at a tertiary eye unit, to assess patient's knowledge of glaucoma and acceptance and subsequent adherence to treatment. METHOD: Information collected prospectively on new glaucoma patients aged 30 or more years included distance from residence and what they knew about glaucoma and its treatment. Treatment offered took account of disease severity and socioeconomic factors. Reasons for not accepting surgery were recorded. At follow up intraocular pressure (IOP) was measured and adherence to medication assessed verbally. Four categories of severity were defined based on visual acuity and visual fields defects in the worse eye. RESULTS: 131 patients were recruited (mean age 52.8 years; 62% male). Most attended because of symptoms (70%). Mean IOP in affected eyes was 31.9+/-SD 12.4 and mean vertical cup:disc ratio was 0.8. 99 eyes (47%) had a visual acuity of light perception or worse. Risk factors for advanced/end-stage disease were age >50 years, living >10 km from the hospital, some awareness of glaucoma, not being literate, being unemployed and presenting with symptoms. In multivariable analysis older age and poor knowledge of glaucoma remained independent risk factors. 75 were offered trabeculectomy: five agreed but only one underwent surgery. Reasons for rejecting surgery were fear (37%), preferred medical treatment (27 %) and cost (15 %). 32/85 (24 %) participants started on topical medication attended follow up. 72% reported excellent compliance but only 56% of glaucomatous eyes had IOPs less than 21 mmHg. CONCLUSIONS: To prevent glaucoma blindness strategies are required which promote earlier detection, with counselling to promote acceptance of and adherence to treatment.