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 Evidence Statements Managing glaucoma in specific population groups – Children Evidence supports using beta-blockers in infants and children where necessary. Evidence suggests using beta-blockers with caution in premature and small infants, as bradycardia, bronchospasm and hypoglycemia have been reported. Evidence indicates caution when using topical and systemic carbonic anhydrase inhibitors in children, in situations where glaucoma is resistant to other treatment and/or prior to surgery. Managing glaucoma in specific population groups – Breastfeeding mothers Evidence supports using beta-blockers in pregnancy, but with caution due to the risks of foetal bradycardia and interuterine growth restriction. Evidence supports laser therapy over surgical techniques in women who are pregnant or planning to conceive in the near future. Evidence Statement Grade C C C C Chapter 10 – Laser therapy and surgery Recommendation 12 Reduce IOP by using laser techniques and incisional surgery Good Practice Points • Offer laser trabeculoplasty as an alternative, or additive to medications. • Offer surgical IOP reduction when medications and/or laser trabeculoplasty fail to meet targets or are unsuitable, and visual disability is threatened. There are inherent risks with invasive procedures, which must be justified by likely benefits. • Glaucoma drainage devices may control IOP long-term and may be suitable if other drainage surgery fails, or as first-line surgery in eyes with higher risks of failure (including inflammatory glaucomas and ICE syndrome). Summary of common laser interventions: Laser options for specific glaucoma classification and stages – Open angle glaucoma Evidence strongly supports argon laser trabeculoplasty for older patients with glaucoma who are at risk of visual loss within their lifetime, particularly when the following factors apply: −− there is difficulty with administering eye drops −− patients are unresponsive to medication alone, or −− patients are poor candidates for incisional surgery. Expert/consensus opinion suggests that patients undergoing laser therapy require continual comprehensive glaucoma monitoring due to the diminishing treatment benefit over time. Summary of common laser interventions: Laser options for specific glaucoma classification and stages – Cyclodestructive procedures in open angle glaucoma Evidence strongly supports using cyclodestructive surgery as a third choice treatment for patients with advanced glaucoma, who are poor candidates for incisional surgery. B B National Health and Medical Research Council 23
NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 1 – Recommendations and Evidence statements Recommendation Recommendation 13 If indicated, perform prophylactic laser peripheral iridotomy in both eyes to prevent progressive anterior segment damage Evidence Statements Summary of common laser interventions: Laser options for specific glaucoma classification and stages – Angle closure – patients with narrow angles/suspected angle closure but low risk status Evidence supports the practice of monitoring patients with suspected angle closure, who are at low risk of immediate closure, until there is evidence of: −− elevated intraocular pressure −− progressive narrowing, or −− development of synechial angle closure. Evidence supports the importance of ensuring that individuals who are being monitored for angle closure (rather than being actively treated) are: −− fully informed of the risks of monitoring −− aware of symptoms of closure, and −− capable of accessing immediate treatment. Where these factors cannot be guaranteed, the patient should be treated as if at high risk. Summary of common laser interventions: Laser options for specific glaucoma classification and stages – Angle closure – patients with suspected angle closure and high-risk status Evidence supports using laser iridotomy for both eyes as the treatment of choice for patients with suspected angle closure, who are at high risk of closure. Summary of common laser interventions: Laser options for specific glaucoma classification and stages – Angle closure – patients with acute angle closure Evidence supports using laser iridotomy with adjunctive pre-operative medication, as the treatment of choice for patients with acute angle closure. Expert/consensus opinion suggests that in patients who experience acute angle closure in one eye, the fellow eye is at high risk of future closure and therefore prophylactic iridotomy can be clinically indicated. Evidence strongly supports using medication to rapidly reduce intraocular pressure as a short-term measure pre-operatively, in patients with acute angle closure glaucoma. Summary of common laser interventions: Laser options for specific glaucoma classification and stages – Angle closure – patients with chronic angle closure and chronic angle closure glaucoma Evidence supports using laser peripheral iridotomy as the treatment of choice in patients with chronic angle closure. Expert/consensus opinion suggests that more than one patent peripheral iridotomy confers no additional benefit. Evidence Statement Grade C C C C A C 24 National Health and Medical Research Council
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