NHMRC Glaucoma Guidelines - ANZGIG

NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA
Chapter 8 – Monitoring: long-term care
• the patient is intolerant of the prescribed medical regimen
• the patient does not adhere to the prescribed medical regimen
• contraindications to individual medicines develop, and/or
• stable optic nerve status and low IOP occurs for a prolonged period in a patient on pressurelowering
medications. Under these circumstances, a carefully monitored attempt to reduce the
medical regimen may be appropriate (AOA 2002).
Downward adjustment of target pressure should be made in the event of progressive optic disc
or VF change. Upward adjustment of target pressure should be considered if the patient has been
stable, and/or if the patient either requires less medication because of side effects, or personal
choice. Whenever regimen changes are implemented, a follow-up visit is indicated within two to
eight weeks to assess the response, as well as side effects from washout of the old medication,
and onset of maximum effect of the new medication (AAO 2005c).
Monitoring recommendations in specific populations
Patients with ocular hypertension or suspected glaucoma
A number of systematic reviews have discussed the importance in the reduction of IOP in patients
with OH to slow the progression to glaucoma (Collaborative Normal-Tension Glaucoma Study
[CNTGS] 1998; Kass, Huerer, Higginbotham et al 2002). The purpose of the follow-up examination
is to periodically evaluate the status of the patient’s IOP, VF, appearance of optic disc and retinal
nerve fibre layer, and to determine if there is evidence of development of glaucomatous damage
(AOA 2005a). These guidelines report consensus of the Working Committee in the absence of
conclusive scientific evidence. The interaction between person and disease is unique for every
patient, and thus management should be individualised. The importance of assessing risk factors
has been previously identified, therefore the recommendations are provided according to risk,
current intervention (if any) and success of achieving target IOP under active management.
Table 8.2 summarises monitoring recommendations for patients with suspected glaucoma.
Any patient who shows evidence of optic nerve deterioration based on optic nerve head appearance,
increased optic disc cupping with rim loss, retinal nerve fibre layer loss, or VF changes consistent
with glaucomatous damage, should be diagnosed as having developed OAG, and treated and
monitored as described for established OAG.
Point of note
Clinical judgement on a case-by-case basis is essential.
For newly diagnosed patients with glaucoma, and those who have undergone significant changes in
treatment, assess the visual field two to three times per year, in the first two years, and then one to
two times per year thereafter depending upon other risks, signs and symptoms.
Image the optic nerve every one to two years in glaucoma suspects and annually in glaucoma
patients. A significant exception is for patients with substantial glaucomatous optic disc damage,
with little remaining nerve tissue, and vertical cup:disc ratios (0.9 – 1.0). In these cases optic nerve
imaging has little chance of detecting change in the remaining few fibres; there may not be a need
to image at all.
Many field abnormalities on initial testing may not reproduce on subsequent tests.
There are a number of techniques which can be used to assess the visual field.
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