NHMRC GuideliNes

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NHMRC Guidelinesfor the Screening, Prognosis, Diagnosis,Management and Prevention of Glaucoma 2010W O R K I N GT OB U I L DAH E A L T H YA U S T R A L I A

Commonwealth of Australia 2010Printed documentThis work is copyright. Apart from any use as permitted under the Copyright Act 1968, no partmay be reproduced by any process without prior written permission from the Commonwealth.Requests and inquiries concerning reproduction and rights should be addressed to the CommonwealthCopyright Administration, Attorney-General’s Department, Robert Garran Offices, National Circuit,Barton ACT 2600 or posted at www.ag.gov.au/cca.ISBN Print: 1864965169Electronic documentThis work is copyright. You may download, display, print and reproduce this material in unalteredform only (retaining this notice) for your personal, noncommercial use or use within yourorganisation. Apart from any use as permitted under the Copyright Act 1968, all other rights arereserved. Requests and inquiries concerning reproduction and rights should be addressed toCommonwealth Copyright Administration, Attorney-General’s Department, National Circuit,Barton ACT 2600 or posted at www.ag.gov.au/cca.ISBN Online: 186496510xNHMRC (National Health and Medical Research Council) NHMRC Guidelines for the screening,prognosis, diagnosis, management and prevention of glaucoma 2010.Contact:National Health and Medical Research CouncilLevel 116 Marcus Clarke StreetCanberra ACT 2601GPO Box 1421Canberra ACT 2601Ph:61 2 6217 9000Fax: 61 2 6217 9100Email: nhmrc@nhmrc.gov.auNHMRC Reference code: CP113

NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMATable of contents Table of contentsAbbreviations1Key guideline sources3Glossary of terms5Guideline development details9PurposeTarget usersGuideline development periodDate of reviewGuideline development teamConflict of interestFundingProcess Report999910101010Chapter 1 – Recommendations and Evidence statements11Chapter 2 – Methods27Underlying research questionsLiterature review processMatrix use for the evidence statementsGuideline developmentReferences2728293030Chapter 3 – Implementation strategies33IntroductionSuggested implementation strategiesReferences333436Chapter 4 – The role of population screeningIntroductionReferences3738Chapter 5 – Prognosis: understanding the natural historyIntroductionNormal tension glaucomaOcular hypertensionEarly primary open angle glaucomaAdvanced primary open angle glaucomaAngle closure glaucomaReferences373939394041434445National Health and Medical Research Counciliii

NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMATable of contentsChapter 6 – Identifying those at risk of developing glaucomaIntroductionRisk factors identified from patient historyRisk factors identified through ocular examinationRisk factors for specific glaucoma types and stagesReferencesAppendix to Chapter 6Chapter 7 – Diagnosis of glaucomaIntroductionDiagnosis of glaucomaMedical historyRisk factorsExamination of eye structureSetting diagnostic baselinesExamination of eye functionDiagnosing specific glaucoma typesProfessional roles in diagnosisSummary of diagnostic standardsQuestions to ask patients with suspected glaucomaQuestions to ask patients with established glaucomaWhat should I examine to identify open angle glaucoma?What should I examine to identify angle closure?ReferencesChapter 8 – Monitoring: long-term careIntroductionMedical historyIntraocular pressureEye structure examinationIndications to change regimenMonitoring recommendations in specific populationsProfessional roles within the teamQuestions to ask your patient with glaucoma at reviewReferencesChapter 9 – MedicationIntroductionHierarchies of interventionStarting medication regimensFacilitating adherenceMedication interactionSide effectsTopical medicationsAssessing medication efficacyChanging medication regimensMedication in acute angle closure crisisAddressing the impact of comorbiditiesManaging glaucoma successfully within specific comorbid conditionsManaging glaucoma in specific population groupsReferencesivNational Health and Medical Research 120121121122124129136

NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMATable of contentsChapter 10 – Laser therapy and surgery139IntroductionSummary of common laser interventionsLaser options for specific glaucoma classification and stagesSummary of common surgical interventionsSurgical options for specific glaucoma classification and stagesTherapeutic indications for laser therapy and or surgeryReferencesAppendix to Chapter 10Chapter 11 – Patient e pathwaysAre care pathways appropriate in glaucoma?Pathways embedded in guidelinesCreating integrated care pathwaysPatient pathways in open angle glaucomaPatient pathways in angle closure glaucomaReferencesChapter 12 – tated organisationsProfession-specific organisationsPregnancy-specific informationAppendix 1: Process report165166167169List of FiguresFigure 7.1Components of the diagnostic processFigure 7.2Diagnostic continuum for patients with glaucomaFigure 8.1 The monitoring cycleFigure 9.1Medication in glaucoma management care decisionsFigure 10.1 The anatomy of the eye (Source: Members of the NHMRC Working Committee)Figure 10.2 An illustration of open angle and angle closure glaucoma withtrabecular meshwork (Source: www.angleclosureglaucoma.cn)Figure 10.3. Purpose of incisional filtering microsurgery(Source: Members of the Working Committee)Figure 10.4 Tube shunts (Source: Members of the Working Committee)Figure 11.1 Open angle glaucoma pathwayFigure 11.2 Intermittent or chronic angle closure pathway666692123140140147148161162National Health and Medical Research Councilv

NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMATable of contentsList of TablesTable 2.1NHMRC Body of Evidence matrix (2009)Table 2.2Exemplar Body of Evidence matrixTable 6.1Risk factors from patient historyTable 6.2Risk factors from ocular examinationTable 7.1Symptoms of angle closureTable 7.2The relative merits of mechanisms of eye structure examinationTable 7.3The relative merits of each form of eye function examinationTable 7.4The relative merits of each form of tonometryTable 7.5Target pressures for diagnostic decision-makingTable 7.6Signs of angle closure: acute intermittent and chronicTable 7.7 Hierarchy of glaucoma examination required for reliable diagnosis, extractedfrom Tuulonen et al (2003) and modified by information from Burgoyne (2004)Table 8.1 Time period (years) required to detect various rates of mean deviation (MD) change with 80% power in visual fields with low, moderate and high degrees of variability with 1 (a), 2 (b) and 3 (c) examinations per year(Chauhan, Garway-Heath, Goñi et al 2008)Table 8.2 Summary of recommendations for monitoring of glaucoma suspects(AAO 2005a,b,c; AOA 2002; South African Glaucoma Society [SAGS] 2006)Table 9.1Medications available in Australia that are used in the management of glaucomaTable 9.2Additive effects of medications used in the treatment of glaucomaTable 9.3 Summary of medications and their respective contraindications, precautionsand interactionsTable 9.4Summary of ocular side effectsTable 9.5A summary of side effectsTable 9.6Medications that may induce angle closure glaucomaTable 9.7Treatment of glaucoma in childrenTable 9.8Summary of medication management for glaucoma during pregnancyTable 9.9Safety of glaucoma medications during lactation (AMH 2009)Table 10.1 Summary of indicators for surgical/laser treatmentsviNational Health and Medical Research 29131134135153

NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMAAbbreviations Acute angle closure crisisAmerican Academy of OphthalmologyAngle closureAngle closure glaucomaAustralian Drug Evaluation CommitteeAdvanced Glaucoma Intervention StudyAppraisal of Guidelines Research and EvaluationAmerican Optometric AssociationCentre for Allied Health EvidenceCritical appraisal skills programmeConfidence intervalCentral corneal thicknessCollaborative Normal Tension Glaucoma StudyDecibelEuropean Glaucoma SocietyEarly Manifest Glaucoma Treatment TrialGuideline Implementability AppraisalGlaucoma Laser TrialJapanese Glaucoma SocietyIntraocular pressureMean deviationMillimetres of mercuryNational Health and Medical Research Council (Australia)National Health Service (UK)NanometreNormal tension glaucomaOpen angle glaucomaOcular hypertensionOcular Hypertension Treatment StudyOdds ratioPrimary angle closurePrimary angle closure glaucomaPrimary open angle glaucomaRelative riskRoyal College of OphthalmologistsSouth African Glaucoma SocietySouth East Asia Glaucoma Interest GroupSwedish interactive threshold algorithmSingapore Ministry of HealthUnited KingdomVisual fieldNational Health and Medical Research Council1

NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMAKey guideline sources Key guideline sourcesAmerican Academy of Ophthalmology [AAO] (2005a): Primary angle closure preferred practicepattern. San Francisco: American Academy of Ophthalmology.American Academy of Ophthalmology [AAO] (2005b): Primary open-angle glaucoma preferredpractice pattern. San Francisco: American Academy of Ophthalmology.American Academy of Ophthalmology [AAO] (2005c): Primary open-angle glaucoma suspectpreferred practice pattern. San Francisco: American Academy of Ophthalmology.American Optometric Association [AOA] (2002): Optometric clinical practice guideline: Care of thepatient with open angle glaucoma (2nd edn.). St Louis: American Optometric Association.European Glaucoma Society [EGS] (2003): Terminology and guidelines for glaucoma (2nd edn.).Savona, Italy: European Glaucoma Society.Japanese Glaucoma Society [JGS] (2004): Guidelines for glaucoma. Tokyo: Japanese Glaucoma Society.Royal College of Ophthalmologists [RCO] (2004): Guidelines for the management of open angleglaucoma and ocular hypertension. London: Royal College of Ophthalmologists.Singapore Ministry of Health [SMOH] (2005): Clinical practice guidelines: Glaucoma. Singapore:Ministry of Health.South African Glaucoma Society [SAGS] (2006): Glaucoma algorithm and guidelines for glaucoma.Hatfield: South African Glaucoma Society.South-East Asia Glaucoma Interest Group [SEAGIG] (2003): Asia Pacific Glaucoma Guidelines.Sydney: South-East Asia Glaucoma Interest Group.Tuulonen A, Airaksinen PJ, Erola E, Forsman E, Friberg K, Kaila M, Klemetti A, Mäkelä M, Oskala P,Puska P, Suoranta L, Teir H, Uusitalo H, Vainio-Jylhä E, Vuori M (2003): The Finnish evidence-basedguideline for open-angle glaucoma. Acta Ophthalmologica Scandinavica; 81(1): 3-18.National Health and Medical Research Council3

NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMAGlossary of terms Glossary of termsAfferent pupillary defectA defect of the pupillary reflex characterised by less constriction of bothpupils when the affected eye is stimulated by light relative to that occurringwhen the unaffected eye is stimulated, as with the swinging flashlight test.The defect is also known as the Marcus Gunn pupil.AfricanThe literature variably refers to the increased risk of glaucoma occurring inpeople of African descent. This refers to people who trace their ancestry toAfrica, whether this be African-Americans, African-Carribbeans, East Africians,Sub-Sarharan Africians or West Africans.Anterior chamberThe space in the eye, filled with aqueous humor that is bordered anteriorlyby the cornea and a small portion of the sclera and posteriorly by a smallportion of the ciliary body, the iris, and that portion of the lens whichpresents through the pupil.Argon lasertrabeculoplastyLight stimulation of the trabecular meshwork of the angle of the anteriorchamber by an argon laser beam to facilitate aqueous humor outflow.Aqueous humorThe clear, watery fluid that fills the anterior and posterior chambers ofthe eye.BiomicroscopyExamination of ocular tissue using a bright focal source of light with a slitof variable width and height and a binocular microscope with variablemagnification.Confocal scanning laserophthalmoscopyThe recording of two-dimensional sectional images for the evaluation ofocular tissue, using a confocal laser imaging system displayed digitally inreal time.Confocal scanninglaser tomographyThe recording of a series of images along the axial axis of the eye enablingthe three-dimensional reconstruction of the topography of the surface ofthe specific tissue under examination using a confocal laser imaging system.Cup:disc ratioThe ratio of the diameter of the area of excavation of the surface of theoptic disc to that of the diameter of the optic disc in any given meridian,often either the horizontal or vertical meridian.ExcitotoxicityThe stimulation of neurons to death by excessive levels of excitatoryneurotransmitters.Filtration surgerySurgical procedures (e.g. thermal sclerostomy, posterior or anterior lipsclerectomy, trephination, trabeculectomy) used to create an alternativepathway for the outflow of aqueous humor to lower intraocular pressure.Fundus photographyThe use of a camera with optics and an illumination system that permitsphotographing the fundus of the eye.Genetic mutationThe alteration of DNA sequencing by changes in the genome.GlaucomaGlaucoma describes a group of eye diseases in which there is progressivedamage to the optic nerve characterised by specific structural abnormalitiesof optic nerve head and associated patterns of visual field loss.National Health and Medical Research Council5

NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMAGlossary of terms6Glaucoma suspectA person suspected of having glaucoma has some but not all of the criteriarequired for a glaucoma diagnosis. They may have one or more of thefollowing: suspicious optic disc, optic disc margin haemorrhage, occludabledrainage angle, peripheral anterior synechiae or elevated intraocular pressure.GonioscopyA diagnostic procedure to examine the angle of the anterior chamber inwhich a specialised corneal contact lens and a biomicroscope are used.Health care providerAny member of the glaucoma team who provides input into the patient’sglaucoma journey. Health care providers involved with glaucoma in Australiamay include, but are not limited to, ophthalmologists, general medicalpractitioners, optometrists, ophthalmic nurses and orthoptists.Intraocular pressureThe pressure within the eye due to the balance between the formation anddrainage of the aqueous humor.Multifactorial inheritanceThe determination of phenotype by multiple genetic and environmentalfactors, each making a small contribution.MyocilinA protein believed to be associated with primary open angle glaucomafound both extraocular and in the trabecular meshwork, optic nerve, retina,cornea, iris, ciliary body, and sclera.MyopiaA vision condition in which close objects are seen clearly, but objects fartheraway appear blurred.Nerve fibre layerThe layer of the retina that comprises unmyelinated axons of retinalganglion cells.NeuroprotectionThe use of pharmacological, genetic alteration, and other means toattenuate a destructive cellular environment thereby protecting neuronsfrom secondary degeneration caused by a variety of primary insults(ischemia/hypoxia, stroke, trauma, degeneration).Neuroretinal rimThe tissue between the optic cup and disc margins.Nocturnal dipThe decrease in systemic blood pressure during sleep.Optic nerveThe cranial nerve (N II) that carries visual impulses from the retina tothe brain.PerimetryDetermination of the extent of the visual field for various types andintensities of stimuli for the purpose of diagnosing and localising disturbancesin the visual pathway.Peripapillary areaTissue surrounding the optic nerve head.PolygenicThe traits or diseases caused by the impact of many genes, each with asmall additive effect on phenotype.Posterior chamberThe space in the eye delimited by the posterior surface of the iris, theciliary processes, and the valleys between them, the zonule of Zinn, and theanterior surface of the crystalline lens. It includes the canal of Hanover, thecanal of Petit, and the retrolental space of Berger.PunctaPuncta are tiny openings along the eyelid margin through which tears drain.National Health and Medical Research Council

NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMAGlossary of termsPulsatile ocularblood flowThe indirect assessment of choroidal blood flow by estimating the influxof blood into the eye during cardiac systole from an evaluation of thecontinuous IOP pulse wave.RefractionClinically, the determination of the refractive errors of an eye, or eyes(e.g. myopia, hyperopia, astigmatism, anisometropia).Reverse pupillary blockBlockage of the movement of aqueous from the anterior to the posteriorchamber leading to a concave anatomical configuration of the peripheral iris.Selective lasertrabeculoplastyUse of a q-switched Nd:YAG laser to target trabecular meshworkendothelial cells without provoking coagulative necrosis, to improveaqueous outflow.Short-wavelengthautomated perimetryA form of automated perimetry that isolates the blue cone mechanismof the visual system by utilising a two-colour incremental thresholdingtechnique consisting of a large blue target on a bright yellow background.TonometryA procedure for measurement of the pressure within the eye.Clinically, tonometry measures the intraocular tension.Trabecular meshworkThe meshwork of connective tissue that is located between the canal ofSchlemm and the anterior chamber, and which is involved in drainage ofaqueous humor from the eye.TrabeculectomySurgical creation of a fistula to allow aqueous outflow from the anteriorchamber to the subconjunctival tissue space, bypassing the trabecularmeshwork/Canal of Schlemm outflow pathway.Visual acuityThe clearness of vision that depends on the sharpness of the retinal imageand the integrity of the retinal and visual pathway. It is expressed as the anglesubtended at the anterior focal point of the eye by the detail of the letter orsymbol recognised.Visual fieldThe area or extent of space visible to an eye in a given position.SourcesAmerican Optometric Association [AOA] (2002): Optometric clinical practice guideline: Care of the patient withopen angle glaucoma (2nd edn.). St Louis: American Optometric Association.Burr J, Azuara-Blanco A, Avenell A (2004): Medical versus surgical interventions for open angle glaucoma.Cochrane Database of Systematic Reviews; 1.Foster PJ, Buhrmann R, Quigley HA, Johnson GJ (2002): The definition and classification of glaucoma inprevalence surveys. British Journal of Ophthalmology; 86(2):238-242.National Health and Medical Research Council7

NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMAGuideline development details Guideline development detailsPurposeThis guideline presents the current best evidence for screening, prognosis, diagnosis, managementand prevention of glaucoma. Its purpose is to inform practice for Australian health care providers,particularly utilising a multi-disciplinary team approach.Target usersThis guideline is primarily targeted to Australian primary health care providers undertaking any taskrelated to screening, prognosis, diagnosis, management and prevention of glaucoma, in any setting.Informa

NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Table of contents List of Tables Table 2.1 NHMRC Body of Evidence matrix (2009) 29 Table 2.2 Exemplar Body of Evidence matrix 30 Table 6.1 Risk factors from patient history 49 Table 6.2 Risk factors from ocular examination 56

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