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 • Appropriate investigations: standard automated perimetry (white-on-white) including comparison with age-corrected normals on a point-wise, regional (eg. hemifield) and global basis, optic disc photography and imaging of the optic nerve and optic nerve fibre layer. • Careful and informed interpretation of results from all imaging and functional tests in order to detect disease or to detect progression. With the multi-faceted nature of glaucoma and the large variability in normal values of all tests, consider results from all tests and assessments. Evidence Statements Setting target intraocular pressure at diagnosis Evidence strongly supports a minimum target intraocular pressure reduction of 20% in patients with suspected primary open angle glaucoma with high-risk status. It is advised that intraocular pressure remains under 24mmHg. Those without high-risk factors can simply be observed. Evidence strongly supports a minimum target intraocular pressure reduction of 20% in patients with early and established primary open angle glaucoma without high-risk status. It is advised that intraocular pressure remains under 16-19mmHg. Evidence strongly supports a minimum target intraocular pressure reduction of 30% in patients with established primary open angle glaucoma with high-risk status, and patients with advanced primary open angle glaucoma. Evidence strongly supports the maintenance of intraocular pressure below 18mmHg in patients with established primary open angle glaucoma, and even lower to below 15mmHg in patients with advanced primary open angle glaucoma. Professional roles in diagnosis Evidence strongly supports that all health care providers involved in glaucoma screening and diagnosis receive appropriate training and continuing support from health care providers who regularly manage glaucoma. Co-management involving an ophthalmologist is recommended. Summary of diagnostic standards Evidence strongly indicates the multifaceted nature of glaucoma and the large variability in the normal values of test findings. This evidence therefore strongly supports using findings from more than one diagnostic procedure or test before a glaucoma diagnosis can be made. Evidence strongly supports the need for health care providers only involved in the screening and diagnosis of glaucoma, to possess the skills and equipment to measure intraocular pressure (by Goldmann Applanation Tonometry or well-calibrated non-contact tonometry), test visual field, perform gonioscopy and examine the optic disc for typical glaucoma signs. They should receive appropriate training and continuing support from health care providers who manage glaucoma. Evidence supports the following assessment methods for diagnosing glaucoma, which are independent of cost and patient preference: −− full medical history examination of eye structure with optic nerve image recording examination of eye function with two automated visual field examinations using a threshold program for determination of the baseline assessment of intraocular pressure, including diurnal variation with a calibrated tonometer checked regularly, and assessment of the angle by gonioscopy. Evidence Statement Grade B B B B A B A B National Health and Medical Research Council 17
<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 8 – Monitoring: long-term care Recommendation 9 Establish a treatment plan, with target IOP Good Practice Point • Target should vary depending on patient setting and risk factors. Monitor response carefully, and use it to modify goals (e.g. lower target IOP) if disease progresses. Change strategies if there are side effects. Medical history Evidence strongly supports taking a comprehensive history at each review. This should include information on what has occurred in the intervening period, and the patient’s ability to adhere to the prescribed medication regimen. Intraocular pressure Evidence strongly supports assessing target intraocular pressure at each ocular review, within the context of glaucomatous progression and quality of life. Evidence strongly supports a further 20% reduction in target intraocular pressure when glaucomatous progression is identified. External structure examination – External eye examination Evidence strongly supports using ocular examination to detect adverse reactions to eye drops, and secondary causes of glaucoma. Evidence supports using a preservative-free preparation when hypersensitivity to topical medication is identified during review. External structure examination – Anterior chamber examination Evidence supports undertaking gonioscopy at review, where there is an unexplained rise in intraocular pressure, suspicion of angle closure and/or after iridotomy. Evidence supports performing gonioscopy regularly in patients with angle closure (three to six times per year) and periodically in those with open angle glaucoma (every one to five years). Expert/consensus opinion suggests monitoring patients with narrow but potentially occludable angles. External structure examination – Nerve fibre layer Evidence strongly supports using validated techniques (with the highest sensitivity and diagnostic odds) to detect changes in visual field or optic disc in order to diagnose early primary open angle glaucoma. Evidence supports the value of validated optic disc comparison techniques (simultaneous stereo photograph comparison and confocal scanning laser tomography) in order to detect longitudinal changes in the optic nerve. Eye function: visual field – Automated perimetry Evidence supports undertaking visual field testing with automated perimetry on multiple occasions at diagnosis, in order to set a reliable baseline. An assessment of likely rate of progression will require two to three field tests per year in the first two years. A A A A B B B A B C 18 National Health and Medical Research Council
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NHMRC Glaucoma Guidelines - ANZGIG

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