NHMRC Glaucoma Guidelines - ANZGIG

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<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 1 – Recommendations and Evidence statements Recommendation Recommendation 7 Assess risk of progression of glaucomatous damage Good Practice Points • Calculate the rate of visual field loss regularly (for example review every four months) for the first two years, and then less frequently (for example every six months) thereafter if stable. This will depend on the health care setting and the individual patient’s risk of progression. • Reduce IOP by 20-50% in patients with glaucomatous optic neuropathy depending on the level of risk to preserve visual field and to reduce progression. • Reduce IOP more aggressively in those patients with greater risk factors for progression. • Patients diagnosed late, with more advanced glaucoma damage, suffer higher rates of progression of visual loss. More aggressive IOP reduction is required. Evidence Statements No Evidence Statements for Recommendation 7. 2 Evidence Statement Grade 2 This recommendation was developed using expert opinion of the Working Committee National Health and Medical Research Council 15
<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 1 – Recommendations and Evidence statements Recommendation Evidence Statements Evidence Statement Grade Chapter 7 – Diagnosis of glaucoma Recommendation 8 Assess with a comprehensive medical history, a full eye examination and investigate appropriately Good Practice Points • A comprehensive medical history: identify all relevant risk factors, relevant comorbidities and concurrent topical and systemic medications, and assess the impact of visual dysfunction, social environment and support networks that may affect adherence to a treatment program. Comorbidities include hypertension, diabetes, thyroid disease, depression, asthma, liver and renal disease. • A full eye examination: anterior segment evaluation including gonioscopy, optic nerve and retinal nerve fibre layer exam stereoscopic optic disc and retinal nerve fibre assessment with a permanent record, IOP and corneal thickness measurements. Diagnosis of glaucoma Evidence strongly supports the need for a comprehensive examination to accurately diagnose all types of glaucoma. This includes a comprehensive medical history, a full eye examination (including gonioscopy), an assessment of eye function (visual field) and measurement of intraocular pressure. Medical History – Risk factors Evidence strongly supports taking a comprehensive history including identification of ocular signs and symptoms, risk factors, relevant comorbid conditions and concurrent medication, to diagnose glaucoma. Expert/consensus opinion suggests that a comprehensive history is required to identify which management approach is most likely to be effective. A comprehensive history includes the potential impact of visual dysfunction, social environment and patient’s support networks that may affect adherence to medication regimens. Examination of eye structure – Setting diagnostic baselines Evidence indicates that an eye structure examination that is capable of establishing a diagnostic baseline includes a stereoscopic view, and a permanent record of the optic disc and retinal nerve fibre layer. Expert/consensus opinion suggests that key components of a baseline optic nerve head examination include size of disc, cup:disc ratio, neuroretinal rim pattern, presence of optic disc haemorrhages and thinning of the nerve fibre layer. Anterior chamber assessment Expert/consensus opinion suggests that gonioscopic examination of both eyes is required when making a diagnosis of glaucoma. Examination of eye function – Perimetry Expert/consensus opinion suggests that visual field testing is invaluable to diagnose glaucoma. Expert/consensus opinion suggests that advancing age, visual acuity, patient capability, concurrent ocular conditions, oculo-facial anatomy and spectacle scotomata all impact upon the results and interpretation of visual field testing. Assessment pressure measurement – Timing of intraocular pressure measurements Evidence indicates that intraocular pressure can vary at different times of the day. Therefore it is important to measure intraocular pressure at different times of the day to gain a comprehensive picture of the intraocular pressure profile of a patient. Assessment pressure measurement – Contact tonometry Evidence strongly supports the need to maximise infection control. Minimum standards are: −− disinfecting equipment before each patient, or −− using disposable covers/prisms with each patient, and between eyes for the same patient. A A C C A 16 National Health and Medical Research Council
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