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 YAG laser peripheral iridotomy creates a small hole in the iris using laser energy to disrupt tissue. This disruption sends fragments of tissue into the aqueous humour which then flows to the trabecular meshwork and can transiently cause blockage and pressure elevation. Normally this is not significant but in patients who are elderly, those with numerous peripheral anterior synechia (hence with little remaining functional trabecular meshwork) or those with an inflammatory component, the risk of pressure elevation may be higher. These patients at higher risk should have their intraocular pressure checked within hours after the laser is performed. Any other patients who may be at risk should also have their pressure checked within hours of the laser being performed. Other patients should have their pressure checked within a week of laser surgery being performed. It is usual for patients to receive a weak topical steroid drop to use several times a day for four or five days following laser iridotomy. Argon laser trabeculoplasty causes burns to the trabecular meshwork which can be inflammatory in nature. It is not uncommon for a pressure rise to occur and this pressure rise appears to be more common in patients with damaged angles from either angle closure; trauma or inflammatory eye conditions. Indeed Argon laser trabeculoplasty in patients with these conditions is frequently considered to be relatively contra-indicated. If Argon laser trabeculoplasty is performed on these patients their pressure should be checked within hours of the laser. Other patients should be checked within a week. These patients will normally be given a weak steroid drop to use several times a day for the first four or five days. Argon laser trabeculoplasty and selective laser trabeculoplasty generally take six weeks to have maximal pressure-lowering effect. Laser iridoplasty generally causes little pressure rise although can cause inflammation. In addition to an alpha-2 agonist, patients should be given a topical steroid 4 times a day for 4 days and be reviewed within a week. Selective laser trabeculoplasty does not cause as much inflammation and a topical steroid is not normally required post-laser, although some clinicians will give patients a single use sample (minims) to use twice a day for one to two days after the laser is performed. Patients with an inflammatory component or with damaged or partly closed angles are at risk of developing a post-laser pressure rise and should be treated as high risk subjects and have their pressure checked within hours of the laser being performed. All patients should have their pressure checked within a week of the laser being performed. Cyclodiode laser uses high powered laser to actually burn the ciliary processes within the eye enough to destroy their function. The power required to do this always causes significant inflammation and usually a lot of pain post-laser. Patients having cyclodiode laser should be given a strong topical steroid (Maxidex or Prednefrin Forte) at least four times a day for several days post-laser. Pain relieving medications such as Panadeine Forte will often be required for several days. IOP spikes in first 24 hours are quite common, so we recommend a pressure check in first 24 hours and prophylactic treatment with medications to minimize any pressure rise. The pressure usually falls within a few days of cyclodiode laser and takes some weeks to stabilise. It is not uncommon for two to three treatments to be performed before a more stable and lower pressure is reached. Post-argon laser trabeculoplasty Monitoring should occur one hour post-operatively. • Measure IOP and check for corneal abrasions. • If normal, re-evaluate patient one to two weeks later. If IOP is elevated or corneal abrasion is present, provide treatment. Monitoring should then occur four to eight weeks post-laser intervention, and then revert to standard monitoring. National Health and Medical Research Council 103
<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 8 – Monitoring: long-term care Post-filtering surgery • Follow-up evaluation should be undertaken by the surgeon on the first post-operative day (12 to 36 hours after surgery). • Evaluation should then occur at least once, from the second to the tenth post-operative day, to evaluate visual acuity, IOP, and status of the anterior segment. • In the absence of complications, additional regular post-operative visits should be undertaken over the next six weeks to evaluate visual acuity, IOP, and status of the anterior segment. • More frequent follow-up visits should occur, as necessary, for patients with post-operative complications such as a flat or shallow anterior chamber, or evidence of early bleb failure, increased inflammation, or Tenon’s cyst formation. After laser therapy or surgical treatment, a proportion of patients will be able to reduce or cease their medication. This may raise issues for monitoring. Health care providers should be sure that patients understand the chronic nature of their disease and the continued need for monitoring. A member of the health care team should take responsibility for monitoring these patients despite their independence from medication management. After surgery for angle closure Following iridotomy, patients should have their angles reassessed to ensure opening of the angle. If the angle has not opened, further intervention (such as peripheral iridoplasty) should be considered. Patients may have an open anterior chamber angle or an anterior chamber angle, with a combination of open sectors, with areas occluded by peripheral anterior synechaie. When associated with glaucomatous optic neuropathy, the latter condition is sometimes designated as combined mechanism glaucoma. Immediate post-operative regimens should include: • Evaluation of the patency of iridotomy • IOP measurement immediately (one to three hours post-operatively), and again at one week. Earlier review may be necessary if the angle is not well opened or the trabecular meshwork is altered. Prophylactic medication should be provided to prevent spikes • Gonioscopy should be repeated as clinically indicated • Fundus examination should be undertaken as clinically indicated (AOA 2005b,c; EGS 2003). After iridotomy, patients may be classified as residual open angle, or a mix of open angle and peripheral anterior synechaie. Patients in whom glaucomatous damage has occurred should be monitored as recommended for POAG. Patients who do not have glaucomatous optic neuropathy should be monitored in a manner similar to a POAG suspect (AAO 2005c). Professional roles within the team Monitoring Disc-imaging and photography can be performed by registered optometrists and ophthalmologists, and may be delegated to other appropriately trained and supervised health care providers. Most diagnostic and therapeutic procedures can be performed safely on an outpatient basis. Most glaucoma management is performed in the out-patient setting. Hospitalisation may be required to ensure adequate application of treatments, such as for poorly responsive acute angle closure attack. This is so patients can be monitored closely after surgical procedures associated with a high risk of 104 National Health and Medical Research Council
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NHMRC Glaucoma Guidelines - ANZGIG

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