NHMRC Glaucoma Guidelines - ANZGIG

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NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 9 – Medication Topical medications Initiating treatment There is general consensus that for most patients with glaucoma, initial medication management should commence in one eye only, using the other eye as a control to check for therapeutic response. Treatment should be initiated with topical medication, the least invasive approach. If possible, treatment should commence in the worst eye, and the response to lowering the IOP should be checked within two to six weeks, as should adherence to the medication regimen and instillation method. Side effects should be regularly assessed. For example, the known maximum IOP-lowering effect of prostaglandin analogues occurs after three to five weeks (EGS 2003). Therefore, response to newly initiated medications should be assessed after two to four weeks. This is generally considered to be a suitable time frame for the medication to reach full effect before extending treatment to the fellow eye. Evidence Statements • Evidence strongly supports initiating or changing medication in one eye, using the fellow eye as a control. • Evidence strongly supports the need for reassessing responses to medication within two to six weeks before extending treatment to the fellow eye. Instillation of topical medications Topical medications often contain preservatives which can cause ocular surface inflammation. Irrespective of the type of topical preparation, patients should be instructed carefully on how best to adminster the medication to the eye to ensure accurate, effective and appropriate instillation. Patients need to understand how to instill topical medications effectively and efficiently. The technique of instillation should be demonstrated to the patient as many times as necessary. The patient needs to be observed instilling the eye drops to ensure that they are able to instill safely, effectively and appropriately. When the patient has a carer who may instill the medication, the carer needs to be trained and observed. The preferred method for eye drop self-instillation includes holding the head horizontal with punctal occlusion and eyelid closure for three minutes (DOUBLE DOT: Digital Occlusion of Tear Duct and Don‘t Open Technique) as systemic absorption can be reduced (by up to 70%) with this technique. If two or more drops are being instilled, there should be an interval of at least five minutes between drops. Patient adherence and capacity to instill eye drops safely and effectively is of paramount importance when determining the most appropriate medication instillation. If more than two topical medications are required to lower the IOP, then other more invasive treatment options should be considered (EGS 2003). Glaucoma Australia has produced a DVD on ‘How to instill eye drops’ with funding from the Department of Health and Ageing. Health care providers are encouraged to become familiar with this resource, and to recommend it to their patients. There are several instillation devices available that may assist patients to instill their medication successfully. National Health and Medical Research Council 119
NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 9 – Medication Evidence Statements • Evidence strongly supports the importance of educating patients in the effective and efficient instillation of topical medications. • Evidence strongly supports teaching patients and carers about the punctal occlusion and eyelid closure technique when instilling eye drops, to reduce systemic absorption. point of note Effective education on the instillation of eye drops includes: • demonstrating the technique to the patient and carers • observing patient and carers instilling the drops correctly • repeating education, demonstration and observation until the heath care provider is satisfied that patient and carers are fully capable of instilling the drops correctly. Assessing medication efficacy Outcome measures Currently, evidence only supports IOP-lowering management as having a beneficial effect on patients’ prognosis. Therefore using a target IOP is the best way to measure the short-term efficacy of a treatment regimen, and medication is thus prescribed to achieve a stable target IOP. Target IOP is a theoretical value that will minimise progression of optic nerve and VF loss, and typically ranges from a 30-50% reduction in pre-treatment (baseline) IOP. Therapeutic efficacy should be judged against the capacity of the intervention to achieve the target value. Target IOPs are not static and may need to be refined given patients’ response to treatment. Glaucoma progression may still occur in individ pparently stable IOP, therefore longitudinal evaluation of the disc and VF are more important than IOP, for determining the longer term success of any given management plan. Evidence Statements • Evidence strongly supports using target intraocular pressure ranges as an early indicator of an effective glaucoma management plan. • Evidence strongly supports monitoring disc and visual field changes as long-term indicators of a successful glaucoma management plan. 120 National Health and Medical Research Council
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