NHMRC Glaucoma Guidelines - ANZGIG

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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. National Health and Medical Research Council 99
NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 8 – Monitoring: long-term care Table 8.2: Summary of recommendations for monitoring of glaucoma suspects (AAO 2005a,b,c; AOA 2002; South African Glaucoma Society [SAGS] 2006) Treatment Status Success Frequency On medication High Risk Achieving target NO NO N/A 6–12/24 months Review Tonometry Gonioscopy Optic nerve and nerve fibre layer Multiple/ every visit Sufficient to set baseline – then annually 6–24 months or every other visit YES N/A 3–12 months 6–18 monthly YES YES YES 3–12 months 6–18 monthly NO
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NHMRC Glaucoma Guidelines - ANZGIG

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