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 Evidence Statements • Evidence strongly supports a minimum target intraocular pressure reduction of 20% in patients with suspected primary open angle glaucoma with high-risk status. It is advised that intraocular pressure remains under 24mmHg. Those without high-risk factors can simply be observed. • Evidence strongly supports a minimum target intraocular pressure reduction of 20% in patients with early and established primary open angle glaucoma without high-risk status. It is advised that intraocular pressure remains under 16-19mmHg. • Evidence strongly supports a minimum target intraocular pressure reduction of 30% in patients with established primary open angle glaucoma with high-risk status, and patients with advanced primary open angle glaucoma. • Evidence strongly supports the maintenance of intraocular pressure below 18mmHg in patients with established primary open angle glaucoma, and even lower to below 15mmHg in patients with advanced primary open angle glaucoma. Point of note Target pressures should always be appropriate to the individual situation/condition. Diagnosing specific glaucoma types Angle closure A definitive diagnosis of AC and ACG requires multiple sources of information. Diagnostic recommendations are based on the stage of disease. Specific examination components should include: • Assessment of refractive status: this is important to assess as hypermetropic eyes, especially in older patients, have narrower anterior-chamber angles and are at increased risk of angle closure. • The size and reactivity of the pupil should be examined: this includes pupil size, regularity and reactivity. • External examination: this includes examining the conjunctival hyperaemia and corneal status • Slit-lamp biomicroscopy: this assesses central and peripheral anterior-chamber depth, anterior chamber inflammation, corneal oedema, iris atrophy (especially sectoral; posterior synechiae; or mid-dilated pupil suggestive of a recent or current attack), signs of previous angle closure attacks (e.g. peripheral anterior synechaie, segmental iris atrophy, glaukomflecken, posterior synechiae, pupillary dysfunction). • A dilated examination: this may not be advisable in patients with anatomic narrow angles or angle closure. • Evaluatation of the fundus and optic nerve: this should use the direct ophthalmoscope or biomicroscope. • For patients with PAC or PACG: pupil dilation might be contraindicated until an iridotomy has been performed. • Gonioscopy of both eyes on all patients: this is undertaken to evaluate angle anatomy, and to detect appositional closure and/or the presence of peripheral anterior synechaie. The frequency and severity of findings will vary between acute, intermittent and chronic forms of closure. Table 7.6 provides a summary extracted from EGS (2003). National Health and Medical Research Council 81
<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 7 – Diagnosis of glaucoma Table 7.6: Signs of angle closure: acute intermittent and chronic SIGN Acute angle closure Intermittent angle closure IOP raised √ Not necessarily √ Reduced visual acuity √ May be normal May be normal Corneal oedema √ Not necessarily NR Pupil mid dilated and unreactive Shallow/flat anterior chamber √ Often round and reactive between attacks √ √ √ Chronic angle closure Iris pushed forward √ Patchy iris atrophy and torsion Peripheral anterior synechaie Gonioscopic closure 360 √ √ √ Venous congestion √ NR NR Fundus changes (disc oedema and splinter haemorrhage) √ Optic disc rim atrophy Substantial glaucomatous damage Bradycardia/arrhythmia √ NR NR NR = not reported NR Pigmentary glaucoma Health care providers should use the same comprehensive evaluation for this type of glaucoma as for POAG, however additional key signs include: • pigment on the anterior surface of the iris often as concentric rings within the iris furrows • spoke-like transillumination defects in the midperiphery of the iris • pigment in the anterior and posterior chambers, and possibly Krukenberg’s spindles on the corneal endothelium • a dense, homogeneously pigmented trabecular meshwork, especially posteriorly • an open, deep anterior chamber angle with possible posterior bowing (concavity) of the iris • rise of the IOP to rather high levels, with dramatic fluctuation • pigment release resulting from pupillary dilation or strenuous exercise which requires assessment of the IOP after dilation. Pseudoexfoliation glaucoma Health care providers should use the same clinical approach for this glaucoma type as the initial and follow-up evaluations of a glaucoma suspect for POAG, with special attention to biomicroscopy and gonioscopy. The evolution from first pigmentary and lens changes to full-scale pseudoexfoliation syndrome may take up to five to ten years. Additional key signs include: • distribution of pseudoexfoliative material on the pupillary margin of the iris and, on the surface of the lens, as a central translucent disc with curled edges surrounded by an annular clear zone • a peripheral granular zone on the anterior surface of the lens, best viewed through a dilated pupil 82 National Health and Medical Research Council
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NHMRC Glaucoma Guidelines - ANZGIG

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