NHMRC Glaucoma Guidelines - ANZGIG

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<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 10 – Laser therapy and surgery Point of note Expert opinion highlights that although the literature is heavily weighted towards argon laser trabeculoplasty, there is also considerable, recent literature about the equivalence of argon laser trabeculoplasty with selective laser trabeculoplasty. Health care providers therefore need to be aware of emerging literature on different techniques and their outcomes. Cyclodestructive procedures in open angle glaucoma Cyclodestructive procedures have been associated with subsequent decrease of visual acuity and, rarely, as sympathetic ophthalmitis. These procedures are less often used as primary treatment, and more often reserved for eyes with reduced visual acuity, and for patients who are poor candidates for incisional surgery (AAO 2005b, Bloom 1997, Egbert 2001, both cited in Burr, Azuara-Blanco & Avenell 2004). According to reviews of short-term follow-up studies, trans-scleral Krypton laser cyclophotocoagulation is often an effective and well-tolerated means of lowering IOP in refractory glaucoma. However, these procedures often need to be repeated (Tuulonen et al 2003). Prior to cyclophotocoagulation, patients should be given additional IOP-lowering medication in order to avoid post-laser pressure spikes (Tuulonen et al 2003). Evidence Statement • Evidence strongly supports using cyclodestructive surgery as a third choice treatment for patients with advanced glaucoma, who are poor candidates for incisional surgery. Angle closure The management aims for any patient with actual or suspected angle closure are to: • re-open or prevent angle closure • control IOP elevation • minimise damage to the optic nerve. Patients with narrow angles/suspected angle closure but low risk status Patients with narrow but open angles, not identified as at immediate risk of closure, and with normal IOP, should be monitored for IOP elevation, progressive narrowing, or development of synechial angle closure (AAO 2005a). While modern laser treatments for glaucoma are relatively safe, all laser interventions incur some risk. Complications from laser iridotomy include increased IOP, corneal, lens, or retinal burns, posterior synechiae, and possible ‘ghost imaging’ in vision. Evidence Statement • Evidence supports the practice of monitoring patients with suspected angle closure, who are at low risk of immediate closure, until there is evidence of: −−elevated intraocular pressure −−progressive narrowing, or −−development of synechial angle closure. National Health and Medical Research Council 143
<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 10 – Laser therapy and surgery Evidence Statement • Evidence supports the importance of ensuring that individuals who are being monitored for angle closure (rather than being actively treated) are: −−fully informed of the risks of monitoring −−aware of symptoms of closure −−capable of accessing immediate treatment. Where these factors cannot be guaranteed, the patient should be treated as if at high risk. Patients with suspected angle closure and high-risk status With improvements in laser techniques, and the consequent changes in risk:benefit ratio, laser iridotomy is indicated for patients with suspected angle closure, who are at high-risk of closure (Saw, Gazzard & Friedman 2003). Circumstances under which this should be considered are (AAO 2005a): • for patients with narrow angles who require repeated pupil dilation for treatment of other eye disorders (e.g. age-related macular degeneration, diabetic retinopathy) • when there is progressive narrowing of the angle • when medication is required which may provoke pupillary block • when symptoms are present that suggest prior angle closure • when the patient’s occupation/avocation makes it difficult to access immediate ophthalmic care (e.g. the patient travels frequently to developing countries, works on merchant vessels), and/or • for the fellow eye in patients who have had an attack of acute primary angle closure (PAC). Evidence Statement • Evidence supports using laser iridotomy for both eyes as the treatment of choice for patients with suspected angle closure, who are at high risk of closure. Patients with acute angle closure For patients with acute angle closure (AAC), the preferred treatment is laser peripheral iridotomy with adjunctive pre-operative medication management to lower IOP, gain corneal clarity, reduce pain and preserve the available VF). If this is impossible due to corneal oedema, the next choice is an incisional iridectomy (Saw et al 2003). There are also other choices including peripheral iridoplasty to break the attack, central corneal indentation and lens extraction. Studies indicate that ‘chronic miotic therapy‘ is not an appropriate alternative either for prophylaxis of the fellow eye, or for treatment of established angle closure, nor is it a substitute for iridotomy (AAO 2005a). There is consistent evidence that in the event of an acute angle closure crisis (AACC) which is a medical emergency, additional systemic medication, such as osmotic diuretics and oral/parenteral carbonic anhydrase inhibitors, may need to be employed to rapidly reduce the IOP to avoid permanent nerve damage and vision loss. The fellow eye of a patient with an attack of AAC should be evaluated since it is at high risk for a similar event. Salmon (1998, cited in AAO 2005a), reports that 39% of fellow eyes treated with miotics will suffer an acute attack within five years, and many eyes with angle closure suffer progressive formation of synechial angle closure with miotic use. 144 National Health and Medical Research Council
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NHMRC Glaucoma Guidelines - ANZGIG

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