NHMRC Glaucoma Guidelines - ANZGIG
NHMRC Glaucoma Guidelines - ANZGIG
NHMRC Glaucoma Guidelines - ANZGIG
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<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA<br />
Chapter 10 – Laser therapy and surgery<br />
Evidence Statement<br />
Evidence supports using intra-operative and post-operative anti-fibrotics to reduce the risk of failure for<br />
patients undergoing incisional surgery.<br />
<strong>Glaucoma</strong> drainage devices<br />
There is no evidence to support the clinical superiority of one aqueous shunt over another<br />
regarding safety or efficacy in reducing IOP. Ophthalmologists should thus base their choice<br />
of device on their own experience, and continue to utilise the shunt with which they are most<br />
comfortable. Tube surgery produces significant long-term IOP control with results suggesting that<br />
IOP control lasts longer than with trabeculectomy (Molteno comparison). Tube surgery tends to<br />
be limited to eyes at higher risk of failure with trabeculectomy or those in which trabeculectomy<br />
has failed. Tube surgery should be considered for the primary procedure in cases of Iridocorneal<br />
Endothelial syndrome, various forms of uveitic (inflammatory) glaucoma, aphakic glaucoma and<br />
in patients whom trabeculectomy is likely to fail (Doe, Budenz, Gedde et al 2001). Such situations<br />
include some severely traumatised eyes and secondary paediatric glaucomas (Molteno et al 2001).<br />
To date there have been no randomised studies which directly compare tube surgery<br />
and trabeculectomy.<br />
Evidence Statements<br />
• Evidence strongly supports using tube surgery for long-term intraocular pressure control. This is an<br />
appropriate first-choice surgery in patients:<br />
−−with eyes at higher risk of failure from trabeculectomy<br />
−−who have failed trabeculectomy<br />
−−with Iridocorneal Endothelial syndrome<br />
−−with various forms of uveitic (inflammatory) glaucoma, or<br />
• with aphakic glaucoma.<br />
Cataract surgery<br />
Results for cataract surgery in glaucoma have been variable and largely dependent on the outcome<br />
measure used. Friedman, Jampel, Lubornski et al (2002) report good evidence that long-term IOP<br />
control is greater with combined procedures than with cataract extraction alone. They report fair<br />
to moderate evidence that trabeculectomy alone lowers long-term IOP more than combined<br />
extra-capsular cataract extraction and trabeculectomy. Friedman and Vedula (2006) indicated that<br />
there was no evidence of benefit with lens extraction in terms of progression of VF loss, visual<br />
acuity or medication use. It was noted that the studies had significant limitations that affected<br />
the ability to draw conclusions, for instance small sample sizes and unit analysis error (where<br />
both eyes were used in some patients). In eyes previously damaged by creeping angle closure,<br />
goniosynechiolysis and trabeculotomy are combined with cataract extraction (plus intraocular<br />
lenses implantation). This works well to reduce IOP and prevent synechasie reformation<br />
(Japanese <strong>Glaucoma</strong> Society [JGS] 2004). Trabeculectomy accelerates the development of cataracts<br />
(AGIS 2000) and promotes tendencies for angle closure due to ciliary block or lens/anterior<br />
segment disproportion. The latter occurs when the increase in lens size from ageing or cataract<br />
leads to crowding and displacement of the ciliary processes and iris, exacerbating plateau iris, iris<br />
to angle proximity and ciliary block, even in the presence of iridotomy. In subjects with persistent<br />
angle narrowing after iridotomy and/or iridoplasty, careful consideration is required regarding the<br />
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