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Glaukooma
Käypä hoito -suositus |  Julkaistu: 2014-10-24   | Tila: voimassa  |  Aihepiiri(t): Silmätaudit, Yleislääketiede
Mikä on Käypä hoito -suositus?
Suomalaisen Lääkäriseuran Duodecimin, Suomen Silmälääkäriyhdistys ry:n ja Suomen Glaukoomaseura ry:n asettama työryhmä
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Glaukooma

Käypä hoito
24.10.2014
Suomalaisen Lääkäriseuran Duodecimin, Suomen Silmälääkäriyhdistys ry:n ja Suomen Glaukoomaseura ry:n asettama työryhmä

Opi ja ota käyttöön

Koosteet

Potilaalle

Miten viitata Käypä hoito -suositukseen? «»1

Suositukseen on laadittu kahdeksan taulua, jotka kokoavat yhteen diagnostiikan, hoidon ja seurannan periaatteet.

  • Glaukooman riskitekijät «»1
  • Suositus glaukoomadiagnoosin tekemisen perusteista «»2
  • Suositus glaukooman tutkimuslöydösten diagnostiikasta «»3
  • Glaukooman hoidon tavoitetaso «»4
  • Suositus glaukooman hoitosuunnitelmasta «»5
  • Tasapainossa olevan glaukoomapotilaan seuranta «»6
  • Tasapainossa olevan glaukooman hoito- ja seurantasuunnitelma 2 vuodeksi eteenpäin «»7
  • Suositus suuririskisen glaukoomapotilaan hoidosta ja seurannasta «»8

Tavoitteet ja rajaukset

  • Suosituksen tavoitteena on yhtenäistää glaukooman hoitokäytäntöjä antamalla näyttöön perustuvat tiedot seuraaviin kysymyksiin:
    1. Mitkä tekijät suurentavat glaukoomaan sairastumisen riskiä?
    2. Mitä tutkimuksia glaukoomadiagnoosia varten tarvitaan?
    3. Kannattaako glaukoomaa seuloa?
    4. Mikä on silmänpaineen alentamisen vaikutus glaukoomapotilailla ja okulaarista hypertensiota sairastavilla: voidaanko taudin etenemistä tai sen aiheuttamaa näkövammaisuutta ehkäistä?
    5. Mitkä hoitomuodot laskevat silmänpainetta, ja millaisia haittavaikutuksia hoidoilla on?
    6. Mikä on hoidon tavoite, ja minkälaista hoitosuunnitelmaa noudatetaan?
    7. Mitä tutkimuksia glaukoomapotilaiden seurannassa tulisi tehdä, ja kuinka usein niitä tulisi tehdä?
    8. Millaisia ovat aggressiivista tai pitkälle edennyttä tautimuotoa sairastavien hoito ja seuranta?
  • Suositus on tarkoitettu sovellettavaksi sekä julkisessa että yksityisessä terveydenhuollossa.
  • Tekstiosuus kattaa tiivistelmän näytönastekatsauksista.
  • Työryhmän suositukset käytännön menettelytavoiksi esitetään taulukkomuodossa (Ks. taulukot liitteistä «»1, «»2, «»3, «»4, «»5, «»6, «»7, «»8).
  • Suosituksessa nimitys avokulmaglaukooma kattaa
    • primaarisen avokulmaglaukooman
    • eksfoliatiivisen glaukooman
    • normaalipaineisen glaukooman.
  • Lisäksi käsitellään okulaarista hypertensiota (kohonnut silmänpaine ilman rakenteellisia ja toiminnallisia vaurioita).
  • Tarkastelun ulkopuolelle jäävät
    • sulkukulmaglaukooma
    • pigmenttiglaukooma ja muut sekundaariset glaukoomat
    • synnynnäinen glaukooma
    • nuoruusiän glaukooma.

Keskeinen sisältö

Taudinkuva ja epidemiologia

Riskitekijät

Taulukko 1. Glaukooman riskiä lisäävät tekijät
1 Lisäksi tumma etninen tausta on todettu riskitekijäksi «Tumma etninen tausta lisää riskiä sairastua glaukoomaan.»C.
Riskitekijät 1 Riskin suuruus Näytönaste
Ikä kaksinkertaistuu noin joka 10. vuosi «Korkea ikä on avokulmaglaukooman tärkeä vaaratekijä.»A
Silmänpaine «Vaikka väestön poikkileikkaustutkimuksissa puolella glaukoomapotilaista silmänpaine on normaali, riski glaukoomavaurioiden syntymiselle kasvaa sitä suuremmaksi, mitä korkeammaksi silmänpaine nousee (erityisesti yli 30 mmHg).»A
22–29 mmHg 10–13-kertainen
> 30–35 mmHg 40-kertainen
Eksfoliaatio yhdessä kohonneen silmänpaineen kanssa 5–10-kertainen «Eksfoliaatiosyndrooma yhdessä kohonneen silmänpaineen kanssa moninkertaistaa avokulmaglaukooma riskin.»B
Näköhermon pään verenvuoto 12-kertainen «Näköhermon pään verenvuoto ilmeisesti lisää glaukooman riskiä, mutta sen puuttuminen ei ole diagnostista.»B
Diabetes 2–3-kertainen «Diabetes saattaa lisätä riskiä sairastua glaukoomaan.»B
Myopia 2-6-kertainen «Likitaitteisuus saattaa lisätä riskiä sairastua glaukoomaan.»C
Sukurasitus 3-kertainen «Positiivinen sukuanamneesi ilmeisesti lisää riskiä sairastua glaukoomaan.»C
Alentunut perfuusiopaine yhdessä korkean iän kanssa 3-kertainen «Alentunut perfuusiopaine näköhermossa saattaa lisätä potilaan riskiä sairastua glaukoomaan.»C

Diagnostiikka

Silmänpaine

Gonioskopia

Rakenne- ja näkökenttämuutosten diagnostiikka

Rakenteellisten muutosten arviointi

Näköhermon pää

Hermosäiekerros

Näköhermon pään ja hermosäiekerroksen kuvantamislaitteet

Näkökenttätutkimus

Seulonta

Silmänpaine

Papillan valokuvaus

Hermosäiekuvaus

Kuvantamislaitteet

Näkökenttätutkimus seulonnassa

Hoidon vaikuttavuus ja kustannusvaikuttavuus

Näkövammaisuus

Glaukooman hoito

  • Valtaosa tutkimuksista on keskittynyt hoidon silmänpainetta alentavan tehon osoittamiseen, koska silmänpaineen alentaminen on toistaiseksi ainoa glaukooman hoitomuoto.

Hoidon teho okulaarisessa hypertensiossa

Hoidon teho avokulmaglaukoomassa

Silmänpaineen alentamiskeinot

Lääkehoito

Yhdistelmävalmisteet

Glaukoomalääkkeiden haittavaikutukset ja allergiset reaktiot

Haittavaikutusten vertailua

Kammiokulman laserhoito

Syklofotokoagulaatio

Leikkaus

Leikkaushoidon teho

Trabekulektomia

Antimetaboliitit

Putki-implantit

Ei-penetroiva kirurgia

Kaihileikkaus

  • Glaukoomaa sairastamattomilla ja sellaisilla glaukoomapotilailla, joiden silmänpaine on ennen leikkausta matala tai lievästi kohonnut, kaihileikkaus (fakoemulsifikaatio + tekomykiö) laskee silmänpainetta 3–4 mmHg «Muut glaukoomaleikkaukset»14. Postoperatiivisen painepiikin riski on kuitenkin huomioitava.

Seuranta

Glaukoomamuutosten etenemisnopeus

Etenemisalttius ja sitä lisäävät tekijät

Rakenne- ja näkökenttämuutosten kliininen vastaavuus

  • Hermosäie-, papilla- ja näkökenttämuutokset tulevat seurannassa tyypillisesti esiin eri aikoina (1–6 vuoden viiveellä), ja niiden korrelaatio yksittäisenä ajankohtana on huono «Hermosäie-, papilla- ja näkokenttämuutosten yhteneväisyys»7.
  • Näkökenttä voi olla papilla- ja hermosäiekerroksen vaurioista huolimatta normaali.
  • Se, minkä testin tulos vaikuttaa muuttuvan ensimmäisenä, riippuu seuranta-ajan alkamiskohdasta ja seurantaikkunan pituudesta.

Automaattiset kuvantamislaitteet ja progressio

Näkökenttätutkimusten taajuus

Näkökenttälöydösten etenemisen arviointi ja insidenssi

Suositus glaukooman seurantataajuudesta

Glaukooman vaikutus elämänlaatuun

Tiivistelmä perusterveydenhuollon lääkäreille

  • Yleislääkärin tulee ensisijaisesti
    • tunnistaa akuutin glaukoomakohtauksen oireet «Glaukooma»4 ja hallita sen diagnostiikka
    • hallita ensihoidon periaatteet.
  • Tässä suosituksessa käsiteltävän avokulmaglaukooman diagnostiikkaan ja seurantaan sen sijaan tarvitaan erikoislaitteistoa ja -osaamista.
  • Normaali keskeinen näöntarkkuus ja viitealueella oleva silmänpaine (10–21 mmHg) eivät sulje pois avokulmaglaukoomaa.
  • Terveyskeskuksissa silmänpaineen mittaukseen soveltuu käytännön syistä parhaiten kimmoketonometri. Sormiperimetrian avulla on mahdollista todeta vain hyvin pitkälle edenneet glaukooman aiheuttamat näkökenttäpuutokset.
  • Paikallisesti käytettävät glaukoomalääkkeet voivat aiheuttaa myös systeemisiä haittavaikutuksia. Ks. kappale Glaukoomalääkkeiden haittavaikutukset ja allergiset reaktiot «»2 ja sähköinen tausta-aineisto «Adverse effects of glaucoma medication (tables 1 and 2)»1.
  • Yleislääkärin on hyvä muistaa glaukooman mahdollisuus erityisesti riskiryhmiin (taulukko «Glaukooman riskiä lisäävät tekijät»1, taulukon tulostettava versio «»1) kuuluvilla potilaillaan ja ohjata heidät mahdollisuuksien mukaan silmälääkärin tutkimuksiin.

Suomalaisen Lääkäriseuran Duodecimin, Suomen Silmälääkäriyhdistys ry:n ja Suomen Glaukoomaseura ry:n asettama työryhmä

Glaukooma-suosituksen historiatiedot «Glaukooma, Käypä hoito -suosituksen historiatiedot»16

Puheenjohtaja:

Anja Tuulonen, LKT, professori; vastuualueen johtaja, Tays Silmäkeskus

Jäsenet:

Eva Forsman, LKT, silmätautien erikoislääkäri; Tammisaaren silmät

Juha Hagman, LT, silmätautien erikoislääkäri; Etelä-Pohjanmaan keskussairaala

Mika Harju, LT, dosentti, silmätautien erikoislääkäri; HYKS:n silmäklinikka

Osmo Kari, LKT, dosentti; Optokari Oy, Espoo

Jorma Komulainen, LT, dosentti, lastentautien ja lastenendokrinologian erikoislääkäri; Suomalainen Lääkäriseura Duodecim, Käypä hoito -toimittaja

Pirkko Lumme, LT, silmätautien erikoislääkäri; Wasaborgin Näkökeskus, Vaasa

Marja Luodonpää, LT, silmätautien erikoislääkäri; OYS:n silmätautien klinikka

Marko Määttä, LT, dosentti, silmätautien erikoislääkäri; HYKS:n silmäklinikka, Helsinki

Ville Saarela, LT, dosentti, silmätautien erikoislääkäri, ylilääkäri; OYS:n silmätautien klinikka

Anu Vaajanen, LT, silmätautien erikoislääkäri; Tays Silmäkeskus

Sidonnaisuudet

Eva Forsman: Ei sidonnaisuuksia.

Juha Hagman:Luentopalkkio (Santen Oy), Koulutus/kongressikuluja yrityksen tuella (Alcon, Allergan, Novartis).

Mika Harju: Luentopalkkio (Santen Oy), Osakeomistus (Silmäasema Fennican osakkeenomistaja, Näkökyky MH Oy omistaja ja toimitusjohtaja), Koulutus/kongressikuluja yrityksen tuella (Alcon, Allergan, Novartis).

Osmo Kari: Ei sidonnaisuuksia.

Jorma Komulainen: Asiantuntijapalkkio (EKSSHP, PKSHP, THL, TUOTA-tutkimushanke), Työsuhde (Duodecim), Luentopalkkio (Lääkäriliitto).

Pirkko Lumme: Botniapharma Oy:n lääketieteellinen johtaja ja osakas. Palkkaa tai palkkioita ei ole maksettu.

Marja Luodonpää: Luentopalkkio (Santen), Koulutus/kongressikuluja yrityksen tuella (Alcon, Allergan).

Marko Määttä: Luentopalkkio (Alcon, Allergan, Santen), Koulutus/kongressikuluja yrityksen tuella (Alcon,Bayer )

Ville Saarela: Luentopalkkio (Santen, Thea). Tutkimusapurahoja (Silmäsäätiö, Glaukoomatukisäätiö Lux).

Anja Tuulonen: Asiantuntijapalkkio (Koncernkontoret, Avdelningen för produktionsstyrning, Region Skåne; Valvira), Johtokunnan jäsenyys, osakeomistus ja työsuhde (Synapsi Oy), Luentopalkkio (Oulun, Tampere ja Aalto yliopistot), Koulutus/kongressikuluja European Glaucoma Society (EGS) tuella. European Glaucoma Society, varapresidentti - teollisuus tukee seuran järjestämiä koulutustilaisuuksia,- Glaucoma Research Society, rahastonhoitaja - teollisuus tukee seuran järjestämiä koulutustilaisuuksia. Tutkimusapurahoja (Tays-EVO, Silmäsäätiö, Glaukoomatukisäätiö Lux).

Anu Vaajanen:Johtokunnan tms jäsenyys (Suomen Glaukoomaseuran sihteeri), Tutkimusapurahoja (Päivikki ja Sakari Sohlbergin Säätiö, Silmäsäätiö, Evald ja Hilda Nissin Säätiö ja Glaukoomatukisäätiö Lux).

Kirjallisuusviite

Glaukooma (online). Suomalaisen Lääkäriseuran Duodecimin, Suomen Silmälääkäriyhdistys ry:n ja Suomen Glaukoomaseura ry:n asettama työryhmä. Helsinki: Suomalainen Lääkäriseura Duodecim, 2014 (viitattu pp.kk.vvvv). Saatavilla internetissä: www.kaypahoito.fi

Tarkemmat viittausohjeet: «http://www.kaypahoito.fi/web/kh/viittaaminen»2

Vastuun rajaus

Käypä hoito -suositukset ovat parhaiden asiantuntijoiden laatimia yhteenvetoja yksittäisten sairauksien diagnostiikan ja hoidon vaikuttavuudesta. Ne eivät korvaa lääkärin tai muun terveydenhuollon ammattilaisen omaa arviota yksittäisen potilaan parhaasta mahdollisesta diagnostiikasta ja hoidosta hoitopäätöksiä tehtäessä.

Tiedonhakukäytäntö

Systemaattinen kirjallisuushaku on hoitosuosituksen perusta. Lue lisää artikkelista khk00007

Kirjallisuutta

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