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Evidence-based Clinical Practice Guidelines for the Management of Glaucoma in the Adult Eye. Canadian Ophthalmological Society. Glaucoma Therapies. Overarching and specific management goals. Preserve visual function. Maintain or enhance overall health-related QOL.
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Evidence-based Clinical Practice Guidelines for the Management of Glaucoma in the Adult Eye Canadian Ophthalmological Society
Overarching and specific management goals • Preserve visual function. • Maintain or enhance overall health-related QOL. • Slow or halt progression of the disease. • Achieved through a careful process of: • observing and monitoring visual function, • providing patient education and support, • providing medical, laser, and (or) surgical interventionas appropriate, and • observation without treatment in some cases. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Quality-of-life considerations • Glaucomatous field damage adversely affects the patient’s QOL.1,2 • Patients with glaucoma report: • Difficulties with bright lights and with light and dark adaptation.3 • Worry or concern about the possibility of blindness. • Difficulty with mobility (falls and motor vehicle accidents).1,4 • A negative impact associated with the therapy itself. 1. Noe G, et al. Clin Experiment Ophthalmol 2003;31:482–6. 2. Altangerel U, et al. Curr Opin Ophthalmol 2003;14:100–5. 3. Janz NK, et al. Ophthalmology 2001;108:887–97. 4 .Haymes SA, et al. Invest Ophthalmol Vis Sci 2007;48:1149–55. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Overall and specific managementgoals in patients with glaucoma Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Lowering IOP • IOP lowering is the only clinically established method of treating glaucoma. • The effectiveness of IOP lowering has been established in several well-designed prospective RCTs.1-4 1. AGIS Investigators. Am J Ophthalmol 2000;130:429–40. 2. Collaborative Normal-Tension Glaucoma Study Group.Am J Ophthalmol 1998;126:487–97. 3. Heijl A, et al. Arch Ophthalmol 2002;120:1268–79. 4. Chauhan BC, et al. Arch Ophthalmol 2008;126:1030–6. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Lowering IOP (cont’d) • Reducing fluctuation in IOP (diurnal and (or) intervisit) may also be a worthwhile objective in select patients, such as those with: • advanced glaucoma, or • disease progression despite seemingly good IOP control, and • PXF glaucoma.1,2 AGIS Investigators. Am J Ophthalmol 2000;130:429–40. Asrani S, et al. J Glaucoma 2000;9:134–42. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Setting target IOP • Formulation of target IOP is one of the most important steps in treatment. • Target IOP is defined as the upper limit of a stable range of measured IOPs deemed likely to retard further optic nerve damage.1 American Academy of Ophthalmology. Primary Open-Angle Glaucoma. Preferred Practice Pattern. San Francisco, CA: American Academy of Ophthalmology; 2005. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Setting target IOP (cont’d) • When setting target IOP, each eye is staged into 1 of 4 severity groups —suspect, early, moderate, or advanced glaucoma —based on: • assessment of the optic nerve and (or) VF • patient factors • age • life expectancy • QOL • risk factors for progression • patient’s own input • There is a fine line between setting an appropriate goal to prevent optic nerve damage, and being overly aggressive in IOP lowering. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Staging each eye forglaucoma damage Adapted from Damji KF, et al. Can J Ophthalmol 2003;38:189–97. *Refers to vertical C/D ratio in an average size nerve. If the nerve is small, then a smaller C/D ratiomay still be significant; conversely, a large nerve may have a large vertical C/D ratio and still bewithin normal limits. †Also consider baseline 10-2 VF (or similar). Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Suggested upper limit of initialtarget IOP for each eye Adapted from Damji KF, et al. Can J Ophthalmol 2003;38:189–97. Note: Target IOP may need to be adjusted during the course of follow-up. Extremes of CCT may be helpful in the setting of target IOP. For example, if the cornea is very thin, this may encourage a more aggressive approach with more frequent follow-up. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Staging severity of glaucoma Recommendation Stage each eye of the patient as normal, suspect, early, moderate or advanced glaucoma based on optic nerve and (or) VF exam [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):S1S93.
Target IOP — setting initial range Recommendation Set upper limit of initial target IOP range for each eye at first visit and then re-evaluate at each visit based on stability/change in structure and function of the optic nerve (i.e., ONH exam with or without additional imaging information as well as VF data) [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):S1S93.