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 Point of note Peaks and troughs in intraocular pressure occur at different times in different people. The true correction for central corneal thickness is not known, and any value is at best an approximation. Non-contact tonometry Pneumatonometry: Air-puff tonometry uses a rapid air pulse to applanate the cornea. Corneal applanation is detected via an electro-optical system. IOP is estimated by detecting the force of the air jet at the instance of applanation. Non-contact tonometry is especially useful for very young children, patients unable to reach a slit lamp due to disability, patients who are uncooperative during applanation tonometry, or patients with corneal disease in whom contact tonometer cannot be accurately performed. In addition, it should be considered for patients who simply cannot tolerate physical contact on the cornea. Alternative forms of tonometry Electronic indentation tonometry Tono-Pen (Reichert, Inc) is a form of electronic indentation tonometry. It is a portable electronic, digital pen-like instrument that determines IOP by making contact with the cornea, after topical anaesthetic eye drops have been applied. Perkins tonometry This is a specific type of portable applanation tonometer to measure IOP in children, patients unable to cooperate for slit lamp exam, and supine anesthetised patients. The relative merits of each form of tonometry are outlined in Table 7.4. This information was extracted from Burr et al (2007). Table 7.4: The relative merits of each form of tonometry IOP measurement Glaucoma stage Sensitivity (95%CI) Specificity (95%CI) DOR (95%CI) Goldmann Applanation Tonometry Non-contact (air-puff) tonometry Pooled all stages 46 (22-71) 95 (89-97) 4.95 (4.48-48.95) Pooled all stages 92 (62-100) 92 (90-94) 134.88 (17.15-1061.1) The use of non-applanation tonometry (i.e. dynamic contour forms) has recently been reported in the literature. There is insufficient evidence to date of the true place of dynamic contour tonometry or other tonometric methods compared to Goldmann Applanation Tonometry. Future updates of this guideline will address this issue should research become available. Point of note To accommodate patient preference and to ensure secondary confirmation of findings, a variety of methods for measuring intraocular pressure are required. National Health and Medical Research Council 79
NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 7 – Diagnosis of glaucoma Setting target intraocular pressure at diagnosis A target IOP should be nominated at diagnosis, depending upon the glaucoma severity, presenting IOP, familial and other risk factors. Usual recommendations suggest a 25% reduction from baseline at diagnosis (Leske, Heijl, Hyman et al 2004; Heigl, Leske, Bengtsson et al 2002) with further 20% reductions if further progression occurs (Canadian Glaucoma Study Group 2006). A lower IOP is required when glaucoma is more severe (The Advanced Glaucoma Intervention Study [AGIS] Investigators 2000, 2002). Target IOPs are outlined in Table 7.5 with reference sources. Table 7.5: Target pressures for diagnostic decision-making Glaucoma classification Individual risk status Percentage lower than compared to pretreatment Specified level Source Glaucoma type Stage Min Max mmHg POAG Suspect Low n/s NR No treatment unless IOP rising 20% SEAGIG(2003) Moderate or not specified 20 NR AAO (2005c) SEAGIG(2003) High 20 NR ≤24mmHg EGS(2003) SEAGIG(2003) Early n/s NR NR ≤19mmHg JGA(2004) Established Moderate 20 NR NR AAO (2005b) RCO(2004) SEAGIG(2003) NR NR ≤16mmHg JGS(2004) High 30 NR Or close to episcleral SEAGIG(2003) venous pressure NR 30 50 NR AOA(2002) Advanced NR NR NR All ≤18mmHg AAO (2005b) EGS(2003) Majority ≤15mmHg RCO(2004) ≤14mmHg NTG NR NR 30 NR Or close to episcleral venous pressure JGS(2004) SEAGIG(2003) JGS(2004) NR = not reported 80 National Health and Medical Research Council
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