NHMRC Glaucoma Guidelines - ANZGIG

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<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 8 – Monitoring: long-term care Patients with suspected glaucoma, and high-risk factors who are undergoing treatment and achieving targets Evidence Statement • Expert/consensus opinion suggests undertaking ocular reviews at three to twelve month intervals for individuals with suspected glaucoma and high-risk factors who are undergoing treatment and achieving targets. Patients with suspected glaucoma, and high-risk factors who are undergoing treatment and failing to achieve targets Whenever medication 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 wash-out of the old medication, and onset of maximum effect of the new medication (AAO 2005c). Evidence Statement • Expert/consensus opinion suggests undertaking ocular reviews at less than four month intervals for individuals with suspected glaucoma, and high-risk factors, who are undergoing treatment and not achieving targets. When treatment is altered, patients should be reviewed within two months. Conversion from suspected to diagnosed open angle glaucoma A patient who shows evidence of glaucomatous optic nerve deterioration (from optic nerve head appearance, optic disc cupping, retinal nerve fibre layer loss, or characteristic VF change) should be diagnosed as having developed primary open angle glaucoma (POAG). Therefore recommended treatment and review processes should occur as indicated in the previous summary table. Newly diagnosed glaucoma It has been identified that two field tests (occasionally three) should be performed in the first year in order account for patient learning and performance improvement. As noted by Chauchan (2008 p.9) ‘clinical decisions on patient management require more than an formulaic approach based on visual field progression because risk factors such as baseline damage, age, and IOP may have different relative weights in driving these decisions’. Therefore the recommendations in this guideline are not a protocol, rather a practical guide and template, to be used within a wider framework of clinical judgement. Established glaucoma Patients with POAG should receive regular follow-up evaluations and care to monitor and treat their disease. The recommendations in this guideline have been produced by a process of combining current recommendations with input from experts in the field. Based on understanding of the effect of CCT on IOP measurements, pachymetry should be repeated after any event (e.g. refractive surgery) that may alter CCT. When monitoring IOP, the frequency of review is dependent upon the achievement of target pressures which were set at baseline. The evidence suggests the following monitoring approach. National Health and Medical Research Council 101
<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 8 – Monitoring: long-term care 1. Target achieved Follow-up reviews are dictated by the stability of the VF and the disc findings. 2. Target not achieved Health care providers should fully review patients’ capability to adhere to the medication regimen. When reviewing patients who have previously undergone surgery, it is important to review drainage blebs. The therapeutic regimen should then be altered, as appropriate. This guideline provides evidence-based hierarchies of choice regarding therapeutic intervention (see the Chapters on medication (9), laser therapy and surgery (10)). Options include increased support for adherence, change of medication, laser or surgery. Frequent review (every four to six weeks) may be required whilst altering treatment and re-establishing baseline IOP. 3. Target not achieved and concurrent fluctuation of intraocular pressure When there is very unstable IOP, more frequent review (every one to four weeks) may be required, whilst altering treatment and re-establishing baseline IOP. Evidence Statements • Expert/consensus opinion suggests that in established glaucoma where intraocular pressure targets are being achieved, monitoring schedules are guided by the severity and stability of disc and visual field examinations. • Expert/consensus opinion suggests that in established glaucoma where intraocular pressure targets are not being achieved, the management plan requires alteration and a review undertaken within four to six weeks. • Expert/consensus opinion suggests that in highly unstable established glaucoma, where intraocular pressure targets are not being achieved, the management plan requires alteration and a review undertaken within one to four weeks. • Evidence supports using tonometry on every visit, for patients with established glaucoma, once a baseline has been set. • Expert/consensus opinion suggests that monitoring timelines for patients with angle closure glaucoma are guided by angle morphology, optic disc and/or visual field stability and intraocular pressure. After surgery for primary open angle glaucoma This section outlines the evidence for monitoring patients after surgery. This evidence has been distilled from guidelines included in this review. Post-laser treatment for glaucoma The laser treatments for glaucoma tend to require very similar post-operative care. The only exception here is cyclodiode laser. The commonest lasers performed for glaucoma are YAG laser iridotomy, Argon laser trabeculoplasty, laser iridoplasty and selective laser trabeculoplasty. All these four laser types can cause an elevation in intraocular pressure which may last from hours to days or weeks. The most likely situation in which this will occur is in elderly patients, those with narrowed angles and, in particular, those with an inflammatory component to their glaucoma. All of these laser procedures should be treated with an alpha-2 agonist (Brimonidine or Iopidine) prior to or just after the laser is performed (using one drop in the treated eye). 102 National Health and Medical Research Council
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NHMRC Glaucoma Guidelines - ANZGIG

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