Canadian Ophthalmological Society

Evidence-based Clinical Practice Guidelines for the Management of Glaucoma in the Adult Eye

Diagnosis of Glaucoma

Diagnosis of glaucoma

• The essential elements of a comprehensive eye examination and patient history form the basis of an examination for glaucoma, 1 with specific attention to: – the evaluation of the optic nerve, – potential risk factors for glaucoma, – the possibility of secondary glaucomas, – concomitant systemic diseases, – medications, and – subjective symptoms .

1. Canadian Ophthalmological Society Clinical Practice Guideline Expert Committee.

Can J

Ophthalmol 2007;42:39 –45.

Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.

Can J Ophthalmol

2009;44(Suppl 1):S1  S93.

Essential elements of the comprehensive glaucoma eye examination

Element

History

Criteria

• Patient name, date of birth, gender, and race • Driving status • Vocation and avocations • Chief complaint, if any (e.g. any perceived visual handicap) • Current medication and allergies (ocular and systemic) • Ocular history • Medical history • Medical and ocular family history (including family history of glaucoma) • Directed review of systems Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.

Can J Ophthalmol

2009;44(Suppl 1):S1  S93.

Essential elements of the comprehensive glaucoma eye examination (cont’d) Element

Clinical examination and investigations

Criteria

• Best corrected distance visual acuity with refraction documented • Pupillary reaction, relative afferent pupillary defect • Automated perimetry • Slit lamp examination of lids, lid margins, conjunctiva, cornea, anterior chamber (clarity and depth), lens • IOP and time of measurement • CCT • Gonioscopy • Dilated examination of:  Lens  Biomicroscopy of ONH and RNF including objective  documentation such as optic disc imaging Fundus Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.

Can J Ophthalmol

2009;44(Suppl 1):S1  S93.

Essential elements of the comprehensive glaucoma eye examination (cont’d) Element

Discussion with patient

Criteria

• Discussion of findings with appropriate correction and mitigating strategy • Counselling with respect to QOL issues (e.g. low vision rehabilitation, adherence) • Follow-up recommendation Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.

Can J Ophthalmol

2009;44(Suppl 1):S1  S93.

Systemic diseases and medications Recommendation

Specific information related to concomitant systemic diseases and medications that may influence glaucoma treatment should be sought [

Consensus

].

Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.

Can J Ophthalmol

2009;44(Suppl 1):S1  S93.

Optic disc cupping — non-glaucomatous causes Recommendation

When considering the diagnosis of glaucoma, particularly when IOPs are in the normal range, specific inquiry should be made with regard to antecedent events that could have resulted in cupping and/or optic atrophy [

Level 4

1 ].

1. Greenfield DS, et al.

Ophthalmology

1998;105:1866 –74.

Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.

Can J Ophthalmol

2009;44(Suppl 1):S1  S93.

Risk Factors for Glaucoma

Risk factors and signs for presence of open-angle glaucoma with level 1 evidence

• • • • • •

Ocular risk factors and signs

IOP Elevated baseline IOP Optic disc Deviation from the ISNT rule* Increased optic disc diameter Parapapillary atrophy • • • • •

Non-ocular risk factors

Increasing age African descent Hispanic ancestry Family history Genetics *ISNT rule; majority of normal optic discs with neuroretinal rims with descending order of thickness —inferior, superior, nasal, temporal.

• • • • • • • • • • • Disc hemorrhage PXF Thinner CCT Pigment dispersion Myopia Decreased ocular perfusion pressure Myocillin Optineurin Apolipoprotein Migraine Corticosteroids Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.

Can J Ophthalmol

2009;44(Suppl 1):S1  S93.

Appendix B: Moderate glaucomatous optic neuropathy

• Localised loss of both inferior and superior neuroretinal rim • A classic inferior notch (small arrow heads) • Nerve fibre layer defect in both superior and inferior arcuate area (large arrow heads) Copyright © 2008 SEAGIG, Sydney. Reproduced with permission from

Asia Pacific Glaucoma Guidelines, 2nd ed

. Hong Kong: Scientific Communications, 208:1-117.

Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.

Can J Ophthalmol

2009;44(Suppl 1):S1  S93.

Appendix B: Advanced glaucomatous optic neuropathy

• Neuroretinal rim thinning • The cup extends to the disc rim • Circumlinear blood vessel baring • Bayoneting of the blood vessels • Parapapillary atrophy Copyright © 2008 SEAGIG, Sydney.

Copyright © 2008 SEAGIG, Sydney. Reproduced with permission from

Asia Pacific Glaucoma Guidelines, 2nd ed

. Hong Kong: Scientific Communications, 208:1-117.

Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.

Can J Ophthalmol

2009;44(Suppl 1):S1  S93 .

Appendix B: Disc hemorrhage

• • • • Splinter, superficial flame shaped, hemorrhage at disc margin (large arrow head) Localised nerve fibre defect at corresponding area (small arrow heads) Laminar dots are visible A deep notch at the inferotemporal neuroretinal rim with broad nerve fibre defect (dark arrow heads) Copyright © 2008 SEAGIG, Sydney. Reproduced with permission from

Asia Pacific Glaucoma Guidelines, 2nd ed

. Hong Kong: Scientific Communications, 208:1-117.

Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.

Can J Ophthalmol

2009;44(Suppl 1):S1  S93.

Risk factors and signs for conversion of ocular hypertension to glaucoma with Level 1 evidence

• • • • •

Ocular risk factors and signs

IOP  Higher baseline IOP Optic disc  Large cup-to-disc ratio  Disc hemorrhage Thinner CCT Myopia Increased pattern standard deviation • • •

Non-ocular risk factors

Increasing age African descent Family history Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.

Can J Ophthalmol

2009;44(Suppl 1):S1  S93.

Risk factor assessment and management decisions Recommendation

Risk factor assessment should be undertaken to facilitate management decisions related to the initiation and augmentation of ocular hypotensive therapy [

Consensus

]

.

Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.

Can J Ophthalmol

2009;44(Suppl 1):S1  S93.

Clinical Examination

Eye examination for glaucoma — essential components Recommendation

The essential features of the clinical examination for glaucoma should include visual acuity, assessment for relative afferent pupillary defect, IOP (as well as method and time of measurement), CCT, gonioscopy, dilated optic disc and fundus evaluation, and VF testing [

Consensus

].

Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.

Can J Ophthalmol

2009;44(Suppl 1):S1  S93.

Sample Glaucoma Referral Letter

Sample glaucoma referral letter

Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.

Can J Ophthalmol

2009;44(Suppl 1):S1  S93.