canadian ophthalmological society evidence-based clinical practice guidelines for the management of...

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):S1S93.

Element Criteria

History • 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

Essential elements of thecomprehensive glaucoma eye examination



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

Element Criteria

Clinical examinationand investigations

• 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



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

Element Criteria

Discussion with patient

• Discussion of findings with appropriate correction and mitigating strategy

• Counselling with respect to QOL issues (e.g. low vision rehabilitation, adherence)

• Follow-up recommendation



Systemic diseases and medications

RecommendationSpecific information related to concomitant systemic diseases and medications that may influence glaucoma treatment should be sought [Consensus].



Optic disc cupping —non-glaucomatous causes

RecommendationWhen 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 41].

1. Greenfield DS, et al. Ophthalmology1998;105:1866–74.



Risk Factors for Glaucoma

Risk factors and signs for presence ofopen-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

• Disc hemorrhage• PXF• Thinner CCT• Pigment dispersion• Myopia• Decreased ocular perfusion

pressure

Non-ocular risk factors

• Increasing age• African descent• Hispanic ancestry• Family history• Genetics

• Myocillin• Optineurin• Apolipoprotein• Migraine• Corticosteroids

*ISNT rule; majority of normal optic discswith neuroretinal rims with descendingorder of thickness—inferior, superior,nasal, temporal. 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.

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 defectin both superior andinferior arcuate area(large arrow heads)

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.

Copyright © 2008 SEAGIG, Sydney. Reproduced with permission from Asia Pacific Glaucoma Guidelines, 2nd ed. Hong Kong: Scientific Communications, 208:1-117.

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.




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)




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



Risk factor assessment and management decisions

RecommendationRisk factor assessment should be undertaken to facilitate management decisions related to the initiation and augmentation of ocular hypotensive therapy [Consensus].



Clinical Examination

Eye examination for glaucoma — essential components

RecommendationThe 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].



Sample GlaucomaReferral Letter

Sample glaucoma referral letter



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