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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
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.
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
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.
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
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.
Systemic diseases and medications
RecommendationSpecific 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):S1S93.
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.
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.
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.
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: 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)
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.
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):S1S93.
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].
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.
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].
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.
Sample GlaucomaReferral 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):S1S93.
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