NHMRC Glaucoma Guidelines - ANZGIG

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NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 10 – Laser therapy and surgery Evidence Statement Evidence supports using intra-operative and post-operative anti-fibrotics to reduce the risk of failure for patients undergoing incisional surgery. Glaucoma drainage devices There is no evidence to support the clinical superiority of one aqueous shunt over another regarding safety or efficacy in reducing IOP. Ophthalmologists should thus base their choice of device on their own experience, and continue to utilise the shunt with which they are most comfortable. Tube surgery produces significant long-term IOP control with results suggesting that IOP control lasts longer than with trabeculectomy (Molteno comparison). Tube surgery tends to be limited to eyes at higher risk of failure with trabeculectomy or those in which trabeculectomy has failed. Tube surgery should be considered for the primary procedure in cases of Iridocorneal Endothelial syndrome, various forms of uveitic (inflammatory) glaucoma, aphakic glaucoma and in patients whom trabeculectomy is likely to fail (Doe, Budenz, Gedde et al 2001). Such situations include some severely traumatised eyes and secondary paediatric glaucomas (Molteno et al 2001). To date there have been no randomised studies which directly compare tube surgery and trabeculectomy. Evidence Statements • Evidence strongly supports using tube surgery for long-term intraocular pressure control. This is an appropriate first-choice surgery in patients: −−with eyes at higher risk of failure from trabeculectomy −−who have failed trabeculectomy −−with Iridocorneal Endothelial syndrome −−with various forms of uveitic (inflammatory) glaucoma, or • with aphakic glaucoma. Cataract surgery Results for cataract surgery in glaucoma have been variable and largely dependent on the outcome measure used. Friedman, Jampel, Lubornski et al (2002) report good evidence that long-term IOP control is greater with combined procedures than with cataract extraction alone. They report fair to moderate evidence that trabeculectomy alone lowers long-term IOP more than combined extra-capsular cataract extraction and trabeculectomy. Friedman and Vedula (2006) indicated that there was no evidence of benefit with lens extraction in terms of progression of VF loss, visual acuity or medication use. It was noted that the studies had significant limitations that affected the ability to draw conclusions, for instance small sample sizes and unit analysis error (where both eyes were used in some patients). In eyes previously damaged by creeping angle closure, goniosynechiolysis and trabeculotomy are combined with cataract extraction (plus intraocular lenses implantation). This works well to reduce IOP and prevent synechasie reformation (Japanese Glaucoma Society [JGS] 2004). Trabeculectomy accelerates the development of cataracts (AGIS 2000) and promotes tendencies for angle closure due to ciliary block or lens/anterior segment disproportion. The latter occurs when the increase in lens size from ageing or cataract leads to crowding and displacement of the ciliary processes and iris, exacerbating plateau iris, iris to angle proximity and ciliary block, even in the presence of iridotomy. In subjects with persistent angle narrowing after iridotomy and/or iridoplasty, careful consideration is required regarding the National Health and Medical Research Council 151
NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 10 – Laser therapy and surgery above angle narrowing factors. It is often safer to remove the lens first and in these situations the angle usually opens further, with a concomitant reduction in IOP. Should the IOP not be reduced sufficiently, then trabeculectomy can be safely performed. In subjects with open angle glaucoma and coexistent cataract requiring trabeculectomy, the consensus is that the cataract should be removed first, when the optic nerve is not severely damaged. In patients with POAG and without prior surgery, approximately 50% will gain a useful reduction in IOP from cataract surgery alone, although this reduction tends to be short-lived (in the order of six months). Should trabeculectomy be required, it can be performed more safely several months later, without risk of inducing cataract. The difficult cases are those with severe glaucoma and cataract, where it is often necessary to perform combined cataract and trabeculectomy surgery to reduce the risk of a pressure spike. Evidence Statement Evidence supports using cataract surgery to open the angle in most patients with primary angle closure, when laser procedures have been inadequate. This is believed to improve the safety of subsequent drainage surgery. Point of note Cataract surgery in patients with advanced glaucoma can lead to loss of remaining vision and/or bleb failure in eyes which have undergone prior trabeculectomy. Therapeutic indications for laser therapy and or surgery Laser therapy is considered in patients who fail to maintain IOP within the specified target range, and who are resistant to other forms of treatment (AOA 2002). Emerging evidence suggests that laser therapy is a strategy for IOP reduction that needs to be considered at different stages of the management spectrum for individual patients, considering its benefits and drawbacks on a one-by-one basis (see Table 10.1). This guideline provides recommendations regarding first, second and third choice treatments. For the role of medication and the indications to change treatment, refer to Chapter 9. 152 National Health and Medical Research Council
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NHMRC Glaucoma Guidelines - ANZGIG

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