NHMRC Glaucoma Guidelines - ANZGIG

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<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 7 – Diagnosis of glaucoma Diagnosis of glaucoma Open angle glaucoma Physical examination should focus on seven elements comprising: • pupil • anterior segment • intraocular pressure (IOP) • central corneal thickness (CCT) • gonioscopy • optic nerve head and retinal nerve fibre layer evaluation • VF sensitivities. Evaluation of the anterior-chamber angle using gonioscopy confirms a diagnosis of primary open angle glaucoma (POAG) by excluding other forms of glaucoma, or secondary causes of IOP elevation such as angle recession, pigment dispersion, peripheral anterior synechiae, angle neovascularisation, and trabecular precipitates. Angle closure The other main mechanism predisposing to glaucoma is angle closure (AC) which can present in either primary or secondary forms, in acute or chronic situations. Patients may have both, and present with acute attacks superimposed on a chronic condition. In primary angle closure (PAC), the eye is at risk of developing glaucomatous optic disc damage, particularly when associated with elevated IOP. When optic disc damage occurs, the eye is deemed to have progressed from PAC to primary angle closure glaucoma (PACG) (American Academy of Ophthalmology [AAO] 2005a). If acute angle closure (AAC) is suspected, some components of the examination (optic disc imaging, VF testing) may need to be postponed as patients may present as medical emergencies. Providing appropriate and timely treatment becomes the priority. Evidence Statement • Evidence strongly supports the need for a comprehensive examination to accurately diagnose all types of glaucoma. This includes a comprehensive medical history, a full eye exam (including gonioscopy), an examination of eye function (visual field) and an assessment of intraocular pressure. Medical history Research consistently indicates that a patient’s history establishes the framework in which a diagnosis of glaucoma is made. The health care provider should review the patient’s family history, and take a complete medical history. The patient’s social situation should also be considered, including the capacity to attend treatment regularly, ability to pay for and adhere to treatment, and affect on the patient’s life/work/family situations. The health care provider should also consider relevant risk factors, as well as make an assessment of the impact of visual dysfunction on quality of life and activities of daily living. For further details on risk assessment see Chapter 6. National Health and Medical Research Council 67
<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 7 – Diagnosis of glaucoma Risk factors This section summarises the risk factors that should be assessed in a medical history. Major • advancing age (exponential) • increasing IOP (exponential) • African-derived (POAG) or Asian-derived (PACG) ethnicity • strong family history • diabetes Minor • rural lifestyle • migraine and peripheral vasospasm (Raynaud’s syndrome) • long-term steroid use • previous eye injury • current cigarette smoking Comorbid conditions • respiratory • cardiovascular disorders • endocrine disorders (e.g. diabetes, thyroid eye disease, pituitary tumours) • central nervous system (e.g. stroke/head injury, early dementia) • psychiatric (e.g. depression) • musculoskeletal conditions which may alter capacity to self-medicate • renal and hepatic disorders • ocular trauma or concurrent ocular conditions (e.g. cataract) • pregnancy or lactation For further details refer to Chapter 6. Evidence Statements • Evidence strongly supports taking a comprehensive history including identification of ocular signs and symptoms, risk factors, relevant comorbid conditions and concurrent medication, to diagnose glaucoma. • Expert/consensus opinion suggests that a comprehensive history is required to identify which management approach is most likely to be effective. A comprehensive history includes the potential impact of visual dysfunction, social environment and patient’s support networks that may affect adherence to medication regimens. 68 National Health and Medical Research Council
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NHMRC Glaucoma Guidelines - ANZGIG

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