NHMRC Glaucoma Guidelines - ANZGIG

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NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 7 – Diagnosis of glaucoma ■ Chapter 7 Diagnosis of glaucoma Recommendation 8 Assess with a comprehensive medical history, a full eye examination and investigate appropriately Good Practice Points • A comprehensive medical history: identify all relevant risk factors, relevant comorbidities and concurrent topical and systemic medications, and assess the impact of visual dysfunction, social environment and support networks that may affect adherence to a treatment program. Comorbidities include hypertension, diabetes, thyroid disease, depression, asthma, liver and renal disease. • A full eye examination: anterior segment evaluation including gonioscopy, optic nerve and retinal nerve fibre layer, stereoscopic optic disc and retinal nerve fibre assessment with a permanent record, IOP and corneal thickness measurements. • Appropriate investigations: standard automated perimetry (white-on-white) including comparison with age-corrected normals on a point-wise, regional (eg. hemifield) and global basis. • Careful and informed interpretation of results from all imaging and functional tests in order to detect disease or to detect progression. With the multi-faceted nature of glaucoma and the large variability in normal values of all tests, consider results from all tests and assessments. Introduction A diagnosis of glaucoma should be made on the basis of multiple sources of information including the presenting history, an assessment of relevant risk factors, and an ocular examination reflecting structure and function of the eye (outlined in Figure 7.1). Initial consultation should elicit a complete medical, surgical, personal and occupational history, and ascertain relevant risk factors (South African Glaucoma Society [SAGS] 2006). This consultation should be followed by a comprehensive clinical examination including slit lamp examination, tonometry, fundus and optic nerve head examination, gonioscopy, and corneal thickness. This examination may be in conjunction with special investigations to document the extent of structural damage to the optic nerve head and the retinal nerve fibre layer, using optic nerve and retinal nerve fibre layer analysis or disc photography, computer-assisted visual field (VF) analysis. Children with suspected glaucoma should be referred to a specialist health care provider in the field. National Health and Medical Research Council 65
NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 7 – Diagnosis of glaucoma Figure 7.1: Components of the diagnostic process HISTORY INTRAOCULAR PRESSURE EYE FUNCTION EYE STRUCTURE Health care providers should be mindful of the different presentations of glaucoma, and the need to use a systematic approach to elicit diagnostic information. In certain cases, glaucoma can present as a medical emergency. Confirmatory diagnosis of glaucoma may require more than one consultation with a health care provider, and the involvement of an ophthalmologist. Moreover diagnosis is not made on the basis of a single test, rather a combination of test methodologies and technological tools. A diagnosis is generally made on the basis of characteristic degenerative changes in the optic disc, and matching defects in VFs. Diagnosis may require repeated longitudinal evaluation and monitoring to document progressive changes (as outlined in Figure 7.2). Optic disc structural review is particularly important, as commonly a loss in disc neuroretinal rim and/or retinal nerve fibre loss is detected prior to VF loss. This so-called ‘pre-perimetric glaucoma’ should be considered as glaucoma, especially where accurate disc-imaging modalities have been used to detect the disc change. Up to 37% of optic nerve fibres need to be lost before a VF defect is identified with standard automated perimetry (Kerrigan, Zack, Quigley et al 1997; Quigley, Nickells, Kerrigan et al 1995). The positive and negative predictive values of the tests applied by any health care provider are important in glaucoma diagnosis. Figure 7.2: Diagnostic continuum for patients with glaucoma Suspected early glaucoma with suspicious optic disc or ocular hypertension Rarely: Acute sudden onset Detection of matching visual field and disc signs Suspected secondary presentation of glaucoma Suspected secondary presentation of glaucoma chronic slow onset 66 National Health and Medical Research Council
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NHMRC Glaucoma Guidelines - ANZGIG

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