NHMRC Glaucoma Guidelines - ANZGIG

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NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 1 – Recommendations and Evidence statements Recommendation Recommendation 10 Monitor patients with primary angleclosure suspect status for progressive angle narrowing, development of synechiae, rising IOP and ischemic changes to the iris or lens Evidence Statements Monitoring recommendations in specific populations – Patients with ocular hypertension or suspected glaucoma Expert/consensus opinion suggests undertaking ocular reviews at six to twenty-four month intervals, for individuals with suspected glaucoma without high-risk factors, who are not receiving treatment. Monitoring recommendations in specific populations – All patients with suspected glaucoma Expert/consensus opinion suggests using automated perimetry at least annually, for patients with suspected glaucoma. Expert/consensus opinion suggests that gonioscopy should be performed at one to five year intervals depending upon degree of angle opening, and presence of prior lens extraction surgery, for patients with suspected primary angle closure glaucoma. Expert/consensus opinion suggests undertaking dilated examination of the optic nerve and optic nerve fibre layer at six to eighteen month intervals for all patients with suspected glaucoma. Undilated examination of the optic disc, looking for change, and presence of disc rim haemorrhage, should be undertaken at most visits. Expert/consensus opinion suggests examination of the optic nerve with validated comparison techniques every one to two years for all patients with suspected glaucoma. Expert/consensus opinion suggests using tonometry at every visit for all patients with suspected glaucoma, once baseline intraocular pressure has been set. Monitoring recommendations in specific populations – Patients with suspected glaucoma, and high-risk factors who are undergoing treatment and achieving targets Expert/consensus opinion suggests undertaking ocular reviews at three to twelve month intervals for individuals with suspected glaucoma and high-risk factors who are undergoing treatment and achieving targets. Monitoring recommendations in specific populations – Patients with suspected glaucoma, and high-risk factors who are undergoing treatment and failing to achieve targets Expert/consensus opinion suggests undertaking ocular reviews at less than four month intervals for individuals with suspected glaucoma, and high-risk factors, who are undergoing treatment and not achieving targets. When treatment is altered, patients should be reviewed within two months. Monitoring recommendations in specific populations – Established glaucoma Expert/consensus opinion suggests that in established glaucoma where intraocular pressure targets are being achieved, monitoring schedules are guided by the severity and stability of disc and visual field examinations. Expert/consensus opinion suggests that in established glaucoma where intraocular pressure targets are not being achieved, the management plan requires alteration and a review undertaken within four to six weeks. Evidence Statement Grade National Health and Medical Research Council 19
NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 1 – Recommendations and Evidence statements Recommendation Chapter 9 – Medication Recommendation 11 Reduce IOP by using medications Good Practice Points • Due to the potential efficacy and once-daily usage, a topical prostaglandin analogue is usually the first choice, unless contraindicated. When more than one agent is required, fixed-dose combinations should be considered to encourage improved compliance. • Topical medications may be the simplest and safest first choice for treatment, except for pregnant and lactating women. • Facilitate adherence and perseverance with a patient-centric self-management approach to a medication plan. Provide ongoing tailored information (such as from Glaucoma Australia) to reinforce a patient’s understanding of glaucoma and realistic goals of treatment. Evidence Statements Expert/consensus opinion suggests that in highly unstable established glaucoma, where intraocular pressure targets are not being achieved, the management plan requires alteration and a review undertaken within one to four weeks. Evidence supports using tonometry on every visit, for patients with established glaucoma, once a baseline has been set. Expert/consensus opinion suggests that monitoring timelines for patients with angle closure glaucoma are guided by angle morphology, optic disc and/or visual field stability and intraocular pressure. Starting medication regimens Evidence strongly supports using topical medications as the simplest and safest first choice for glaucoma management. Evidence strongly supports limiting the use of systemic medication to situations where patients cannot tolerate topical medications, are unable to safely and effectively instill topical medications, are failing to achieve intraocular pressure targets, or when laser therapy or surgery either had poor outcomes, or are contraindicated. Evidence strongly supports using a topical prostaglandin analogue or beta-blocker in the initial management of glaucoma unless contraindicated. Evidence strongly supports carbonic anhydrase inhibitors and alpha 2 -agonists as second and third choice medication management, with dosing regimens of two to three times daily. Facilitating adherence Evidence supports a patient-centric self-management approach that facilitates optimal adherence to the medication management plan. Evidence supports the value of ongoing, tailored information to support patients’ understanding of their disease and its management. Evidence strongly supports using combination preparations, rather than separate instillations of individual medications, to improve patient adherence. There is no evidence however, showing that one combination preparation is more effective than any other for reaching target intraocular pressure. Medication interaction Expert/consensus opinion suggests the need to establish the presence of other disease states when initiating, assessing or altering medication regimens for patients with glaucoma. These include, but are not limited to, diabetes, depression, hyperthyroidism, heart disease, asthma, liver and renal impairment. Evidence Statement Grade A A A A B B A 20 National Health and Medical Research Council
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NHMRC Glaucoma Guidelines - ANZGIG

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