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 • Initiate, switch or add medications to one eye, using the other eye as a “control”. In these cases, reassess IOP within 2-6 weeks before treating the other eye. If there is no apparent effect check for adherence. • Teach patients the “double DOT” (Don’t Open Technique and Digital Occlusion of Tear ducts) for 2-3 minutes post-instillation to minimise systemic absorption and to promote ocular penetration of eyedrops. • Demonstrate instillation techniques, observe patient or carer instilling drops and repeat education till ability to instil has been proven. Evidence Statements Side effects Evidence strongly warns of the significant potential side effects from both topical and systemic medications in the management of glaucoma. Topical medications – Initiating treatment Evidence strongly supports initiating or changing medication in one eye, using the fellow eye as a control. Evidence strongly supports the need for reassessing responses to medication within two to six weeks before extending treatment to the fellow eye. Topical medications – Instillation of topical medications Evidence strongly supports the importance of educating patients in the effective and efficient instillation of topical medications. Evidence strongly supports teaching patients and carers about the punctal occlusion and eyelid closure technique when instilling eye drops, to reduce systemic absorption. Assessing medication efficacy – Outcome measures Evidence strongly supports using target intraocular pressure ranges as an early indicator of an effective glaucoma management plan. Evidence strongly supports monitoring disc and visual field changes as long-term indicators of a successful glaucoma management plan. Changing medication regimens Evidence strongly indicates that, where the medication regimen is well tolerated, the main indicator for changing it is failure to reach target intraocular pressures. Evidence strongly supports substitution rather than addition of medication when treatment is ineffective. Evidence strongly supports that when two or more topical medications are ineffective, consideration is given to laser therapy or surgery instead of systemic medications. Medication in acute angle closure crisis Evidence strongly supports using adjunct medications including cholinergics (miotics), hyperosmotic medications and carbonic anhydrase inhibitors to rapidly reduce intraocular pressure prior to surgery. Managing glaucoma successfully within specific comorbid conditions – Diabetes Evidence indicates caution when prescribing topical beta-blockers to patients with diabetes. Managing glaucoma successfully within specific comorbid conditions – Depression Evidence indicates caution when prescribing alpha 2 -agonists or beta-blockers for patients with depression. Evidence supports the needs for an ophthalmic consultation for patients at risk of increased intraocular pressure, prior to commencing medications for depression, and periodically during treatment for depression. Evidence Statement Grade A A A A A A A A A A A C C B National Health and Medical Research Council 21
<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 1 – Recommendations and Evidence statements Recommendation Evidence Statements Managing glaucoma successfully within specific comorbid conditions – Asthma Evidence indicates that using non-selective beta-blockers is generally contraindicated in patients with asthma, however cardio-selective beta-blockers may be used with caution. Managing glaucoma successfully within specific comorbid conditions – Chronic obstructive pulmonary disease Evidence indicates using beta-blockers with caution in patients with chronic obstructive pulmonary disease. Preference may be given to using cardio-selective beta-blockers as they are less likely to induce bronchospasm. Managing glaucoma successfully within specific comorbid conditions – Cardiovascular disease Evidence indicates using alpha 2 -agonists with caution in patients with severe cardiovascular disease. A specialist cardiac opinion may be required for individual cases. Evidence indicates using beta-blockers with caution in patients with existing heart disease. Using these medications is contraindicated in patients with bradycardia (45–50 beats/minute), sick sinus syndrome, second or third degree atrioventricular block, severe hypotension or uncontrolled heart failure. Managing glaucoma successfully within specific comorbid conditions – Hepatic impairment Evidence indicates that systemic carbonic anhydrase inhibitors are contraindicated in patients with hepatic impairment, while topical carbonic anhydrase inhibitors may be used with caution. Managing glaucoma successfully within specific comorbid conditions – Renal impairment Evidence indicates that caution is required when considering systemic carbonic anhydrase inhibitors for patients with mild to moderate renal impairment, and these medications are contraindicated in patients with severe renal impairment. Medication-induced glaucoma Evidence indicates caution in the administration of corticosteroids delivered by any form (i.e. oral, intranasal or ocular) for patients with glaucoma or ocular hypertension. Evidence supports obtaining a comprehensive medication history from all patients with ocular symptoms suggestive of acute or chronic angle closure glaucoma, to rule out potential medication-induced glaucoma. Evidence Statement Grade B B B B B B B B 22 National Health and Medical Research Council
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