NHMRC Glaucoma Guidelines - ANZGIG

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NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 5 – Prognosis: understanding the natural history Evidence suggests that topical pressure-lowering treatment is effective for most individuals, as it reduces the rate of progression of OH (Maier et al 2007) or early POAG (de Moura, Paranhos & Wormald 2007). Therefore an individual’s prognosis may be significantly improved by undertaking appropriate treatment. The trade-offs between treatment benefits and side effects should be considered on a case-by-case basis. There is a substantial risk of developing cataracts with all glaucoma interventions. It is thus important to assess an individual’s risk of developing cataracts and to monitor this on an ongoing basis, whilst undergoing treatment. There is a need to balance treatment benefits with side effects. The aim of treatment thus may be to minimise glaucomatous progression and congruently reduce the risk of visual loss within an individual’s lifetime, rather than to prevent any level of glaucoma progression (European Guidelines Society [EGS] 2003). These guidelines provide recommendations for risk assessment (Chapter 6) and therapeutic interventions (Chapters 9 and 10). Evidence Statements • Evidence strongly supports implementing appropriate management plans for patients with early primary open angle glaucoma in order to reduce the risk of visual loss, and minimise glaucomatous progression within the patient’s expected lifespan. • Evidence strongly supports management plans that are based on an evaluation of the relative benefits and risks of treatment for each patient with glaucoma. Communication with patients With treatment 20 years ago, the average time to unilateral blindness for patients with primary open angle glaucoma was approximately 17 years. Untreated patients progress at approximately twice the speed of treated patients. In the last 20 years the rates of glaucoma blindness have dropped due to earlier diagnosis and more effective intraocular pressure-lowering treatment which significantly improves prognosis in the majority of cases. It is therefore important to comply with treatment and discuss any concerns with treatment with your health care provider. Advanced primary open angle glaucoma Rates of progression in subjects with high IOP (>30mmHg) are generally acknowledged to be greater than those previously described by early stage population-based studies. Patients with more severe glaucoma at diagnosis (i.e. those diagnosed later) are more likely to go blind (Oliver et al 2002). There is scant evidence on the impact of risk factors on the progression and outcomes of patients with severe and advanced glaucoma. The results of the Advanced Glaucoma Intervention Study reported by Friedman et al (2004) suggest that older age, lower formal education, male gender and diabetes are significant risk factors for the progression of advanced glaucoma to blindness. Reduction in maximal IOP and IOP fluctuation has some benefits for some patients, even in the advanced stage of glaucoma. However not every individual will gain the same benefits from treatment. A larger reduction in IOP is required to prevent progression in patients with more advanced glaucoma, when loss of vision is threatened. Patients with IOP below 14mmHg are reported to have the least progression (Tuulonnen, Airaksinen, Erola et al 2003). Target IOPs are discussed in Chapter 7. National Health and Medical Research Council 43
NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 5 – Prognosis: understanding the natural history Communication with patients Higher rates of progression and visual loss may occur in patients who have been diagnosed late, or who already suffer from more advanced forms of glaucoma. However, evidence continues to support the benefits of active intraocular pressure reduction, even when patients have advanced stage glaucoma. Angle closure glaucoma Primary angle closure glaucoma is a generic term for a group of related conditions without physical or inflammatory causes leading to narrowing, then closure of the angle, finally raised intraocular pressure produces ischemic iris changes and glaucoma-related optic nerve damage. Most patients pass through each of these phases and each of these phases has been given a name and defining features (Yip & Foster 2006). Primary angle closure suspect (PACS) is an anatomical predisposition to closure with signs of narrowing of the angle (appositional contact between iris and trabecular meshwork) but without permanent occlusion or signs of adhesion (synechiae) between the iris and trabecular meshwork. Primary angle closure (PAC) is a partially or totally closed angle with synechia and/or raised intraocular pressure. The optic disc and visual field are still normal but the iris shows signs of ischemic insult such as whorls or small anterior lens opacities (glaucomflecken) are present. Primary angle closure glaucoma (PACG) includes PAC with glaucomatous changes in the optic disc (neuroretinal rim loss, cupping and excavation) along with visual field changes. The treatment of primary angle closure-related glaucoma is two-fold; one is to manage the compromised angle and the other is to manage the glaucomatous nerve damage which is no different to the management of primary open angle glaucoma. Moreover, the prognosis regarding visual field and optic disc damage is thought to be identical, depending upon the pressure and patient susceptibility, so the previous section on primary open angle glaucoma prognosis is thought to pertain to angle closure. The rate of developing PAC in 129 Americans classified as PACS and followed for up to five years was found to be 19.4% after 2.7 years (Wilensky et al 1993). The risk of progressing from PACS to PAC in Indians is 22% at five years (Thomas et al 2003a). Very few Indian patients with PACS progress to PAC 4 years after laser iridotomy (Pandav et al 2007). Rate of progression from PAC to primary angle closure glaucoma. In untreated Indians is approximately 37% over several years (Thomas et al 2003b). Following laser iridotomy this rate drops to 3% at 2 years in Mongolians (Nolan et al 2000) and 9 - 11% in Indians at 4 to 5 years (Pandav et al 2007; Thomas et al 2003b). Rate of progression of treated primary angle closure glaucoma. Laser iridotomy is commonly thought to reduce the rate of progression by maintaining an open angle and allowing greater efficacy of medications. However, approximately 48% of Mongolian subjects with primary angle closure glaucoma who have laser iridotomy will still require glaucoma drainage surgery within two years of the iridotomy (Nolan et al 2000). These reported rates are similar to those in an Indian population (Pandav et al 2007). 44 National Health and Medical Research Council
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