NHMRC Glaucoma Guidelines - ANZGIG

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<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 5 – Prognosis: understanding the natural history Evidence Statements • Evidence strongly supports assessing risk of conversion of ocular hypertension to glaucoma, using factors such as intraocular pressure and central corneal thickness, in order to guide decision-making concerning which patients with ocular hypertension warrant treatment. • Evidence strongly supports intervention for individuals with ocular hypertension and major risk factors for the development or progression of glaucoma, in order to reduce the risk of visual loss within their expected lifespan. −−Major risk factors for developing glaucoma include elevated intraocular pressure, increased cup:disc ratio, disc rim haemorrhage, reduced central corneal thickness, older age, strong family history and ethnicity. −−Major risk factors for glaucoma progression include elevated and/or fluctuating intraocular pressure, increased cup:disc ratio, disc rim haemorrhage and reduced central corneal thickness. • Evidence strongly supports careful monitoring, rather than active treatment of patients with ocular hypertension and low-risk status. • Evidence strongly supports monitoring in order to detect conversion to glaucoma for all patients with ocular hypertension, frequency depending on other identified risk factors. Refer to Table 8.2 on p100. Communication with patients It is essential that patients understand the risks for, and consequences of, progression to glaucoma and the value of treatment. Rates of conversion to glaucoma are initially low, however any progression and visual loss is irreversible. Timely treatment can reduce the chance of progression and/or conversion by 50%. Early primary open angle glaucoma The literature provides sound evidence that without treatment, individuals with OH and early POAG will convert more rapidly to advanced stages of the disease, with the inherent risks of VF loss. A recent systematic review reports an estimate of the likely time to progress to blindness from open angle glaucoma without treatment as 23 years, and with treatment, as 35 years (Burr et al 2007). Mathematical model data presented by Burr et al (2007) concerning patients with OH and glaucoma shows a linear rate of blindness of 9% in both eyes at 20 years after diagnosis, and 26% unilateral blindness at the same follow-up point. Hattenhauer, Johnson, Ing et al (1998) provide the following estimation of time to blindness. Follow-up of subjects with diagnosed glaucoma found that after 20 years, 22% were bilaterally blind and 54% were unilaterally blind (Hattenhauer et al 1998; Oliver, Hattenhauer, Herman et al 2002). The risk of blindness in one eye in treated classic glaucoma was 50% at 17 years in those diagnosed between 1965 and 1980 at the Mayo clinic (Burr et al 2007). Without treatment it would have been much more rapid. Recent advances in treatment and earlier diagnosis have probably improved the prognosis. Indicative timelines to blindness for glaucoma and OH are reproduced below from Hattenhauer et al (1998 p1202-1203). National Health and Medical Research Council 41
<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 5 – Prognosis: understanding the natural history % 100 90 80 70 –– - Classic glaucoma ––– Treated ocular hypertension 60 50 40 30 20 10 0 0 5 10 15 20 Years Figure 2: Kaplan-Meier cumulative probability of glaucoma-related blindness in both eyes for treated ocular hpertension and classic glaucoma % 100 90 80 70 –– - Classic glaucoma ––– Treated ocular hypertension 60 50 40 30 20 10 0 0 5 10 Years Figure 4: Kaplan-Meier cumulative probability of glaucoma-related blindness in at least one eye for treated ocular hypertension and classic glaucoma. Source: Hattenhauer et al (1998 p1202-1203) 15 20 42 National Health and Medical Research Council
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