Statement of Principles

concerning

OPEN-ANGLE GLAUCOMA
(Reasonable Hypothesis)

(No. 49 of 2021)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.

Dated                                           23 April 2021

Contents

1 Name

2 Commencement

3 Authority

4 Repeal

5 Application

6 Definitions

7 Kind of injury, disease or death to which this Statement of Principles relates

8 Basis for determining the factors

9 Factors that must exist

10 Relationship to service

11 Factors referring to an injury or disease covered by another Statement of Principles

Schedule 1 - Dictionary

1 Definitions

1               Name

This is the Statement of Principles concerning open-angle glaucoma (Reasonable Hypothesis) (No. 49 of 2021).

2               Commencement

              This instrument commences on 24 May 2021.

3               Authority

This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986.

4               Repeal

The Statement of Principles concerning open-angle glaucoma No. 27 of 2012 (Federal Register of Legislation No. F2012L00457) made under subsections 196B(2) and (8) of the VEA is repealed.

5               Application

This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies.

6               Definitions

The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.

7               Kind of injury, disease or death to which this Statement of Principles relates

(1)          This Statement of Principles is about open-angle glaucoma and death from open-angle glaucoma.

Meaning of open-angle glaucoma

(2)          For the purposes of this Statement of Principles, open-angle glaucoma:

(a)          means an acquired, progressive optic neuropathy involving characteristic optic disc abnormalities and associated visual field defects, occurring in the presence of an open iridocorneal angle and usually associated with raised intraocular pressure; and

(b)          includes normal tension glaucoma; and

(c)          excludes congenital, infantile or development glaucomas.

Note 1: Open-angle glaucoma may be primary, or secondary to another eye disorder.

Note 2: Open-angle glaucoma may be asymptomatic until the optic nerve damage is severe.

(3)          While open-angle glaucoma attracts ICD‑10‑AM code H40.1, in applying this Statement of Principles the meaning of open-angle glaucoma is that given in subsection (2).

(4)          For subsection (3), a reference to an ICD-10-AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4.

Death from open-angle glaucoma

(5)          For the purposes of this Statement of Principles, open-angle glaucoma, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's open-angle glaucoma.

Note: terminal event is defined in the Schedule 1 - Dictionary.

8               Basis for determining the factors

The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that open-angle glaucoma and death from open-angle glaucoma can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the MRCA.

Note: MRCA, relevant service and VEA are defined in the Schedule 1 - Dictionary.

9               Factors that must exist

At least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting open-angle glaucoma or death from open-angle glaucoma with the circumstances of a person's relevant service:

(1)          having glucocorticoid therapy as specified, before the clinical onset of open-angle glaucoma, and where the glucocorticoid therapy as specified has ceased, the last dose of the therapy was received within the three months before the clinical onset of open-angle glaucoma;

Note: glucocorticoid therapy as specified is defined in the Schedule 1 - Dictionary.

(2)          having uveitis, scleritis or episcleritis at the time of the clinical onset of open-angle glaucoma;

Note: uveitis, scleritis and episcleritis are defined in the Schedule 1 - Dictionary.

(3)          having:

(a)          a benign or malignant neoplasm; or

(b)          a non-neoplastic lesion;

of the affected eye at the time of the clinical onset of open-angle glaucoma;

Note 1: Examples of a benign or malignant neoplasm include lymphoma, trabecular meshwork melanoma, choroidal metastasis and retinoblastoma.

Note 2: Examples of a non-neoplastic lesion include cyst, ocular haemorrhage (including ghost cells), leakage of lens protein or lens particles and vascular malformation or thrombosis.

(4)          having growth of new blood vessels (neovascularisation) of the iridocorneal angle due to a condition or procedure involving the affected eye from the specified list of conditions or procedures, before the clinical onset of open-angle glaucoma;

Note: specified list of conditions or procedures is defined in the Schedule 1 - Dictionary.

(5)          having trauma to the affected eye before the clinical onset of
open-angle glaucoma;

Note: trauma is defined in the Schedule 1 - Dictionary.

(6)          having sympathetic ophthalmia at the time of the clinical onset of open-angle glaucoma;

Note: sympathetic ophthalmia is defined in the Schedule 1 - Dictionary.

(7)          having intraocular surgery to the affected eye before the clinical onset of open-angle glaucoma;

(8)          undergoing a course of therapeutic radiation for cancer, where the affected eye was in the field of radiation, before the clinical onset of open-angle glaucoma;

(9)          having a disease from the specified list of endocrine diseases within the 12 months before the clinical onset of open-angle glaucoma;

Note: specified list of endocrine diseases is defined in the Schedule 1 - Dictionary.

(10)      having hypertension before the clinical onset of open-angle glaucoma;

(11)      having dyslipidaemia before the clinical onset of open-angle glaucoma;

Note: dyslipidaemia is defined in the Schedule 1 - Dictionary.

(12)      having glucocorticoid therapy as specified, before the clinical worsening of open-angle glaucoma, and where the glucocorticoid therapy as specified has ceased, the last dose of the therapy was received within the three months before the clinical worsening of
open-angle glaucoma;

Note: glucocorticoid therapy as specified is defined in the Schedule 1 - Dictionary.

(13)      having uveitis, scleritis or episcleritis at the time of the clinical worsening of open-angle glaucoma;

Note: uveitis, scleritis and episcleritis are defined in the Schedule 1 - Dictionary.

(14)      having:

(a)          a benign or malignant neoplasm; or

(b)          a non-neoplastic lesion;

of the affected eye at the time of the clinical worsening of open-angle glaucoma;

Note 1: Examples of a benign or malignant neoplasm include lymphoma, trabecular meshwork melanoma, choroidal metastasis and retinoblastoma.

Note 2: Examples of a non-neoplastic lesion include cyst, ocular haemorrhage (including ghost cells), leakage of lens protein or lens particles and vascular malformation or thrombosis.

(15)      having growth of new blood vessels (neovascularisation) of the iridocorneal angle due to a condition or procedure involving the affected eye from the specified list of conditions or procedures, before the clinical worsening of open-angle glaucoma;

Note: specified list of conditions or procedures is defined in the Schedule 1 - Dictionary.

(16)      having trauma to the affected eye before the clinical worsening  of open-angle glaucoma;

Note: trauma is defined in the Schedule 1 - Dictionary.

(17)      having sympathetic ophthalmia at the time of the clinical worsening of open-angle glaucoma;

Note: sympathetic ophthalmia is defined in the Schedule 1 - Dictionary.

(18)      having intraocular surgery to the affected eye before the clinical worsening of open-angle glaucoma;

(19)      undergoing a course of therapeutic radiation for cancer, where the affected eye was in the field of radiation, before the clinical worsening of open-angle glaucoma;

(20)      having a disease from the specified list of endocrine diseases within the 12 months before the clinical worsening of open-angle glaucoma;

Note: specified list of endocrine diseases is defined in the Schedule 1 - Dictionary.

(21)      having hypertension before the clinical worsening of open-angle glaucoma;

(22)      having dyslipidaemia before the clinical worsening of open-angle glaucoma;

Note: dyslipidaemia is defined in the Schedule 1 - Dictionary.

(23)      inability to obtain appropriate clinical management for open-angle glaucoma.

10           Relationship to service

(1)          The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person.

(2)          The factors set out in subsections 9(12) to 9(23) apply only to material contribution to, or aggravation of, open-angle glaucoma where the person's open-angle glaucoma was suffered or contracted before or during (but did not arise out of) the person's relevant service.

11           Factors referring to an injury or disease covered by another Statement of Principles

In this Statement of Principles:

(1)          if a factor referred to in section 9 applies in relation to a person; and

(2)          that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(2) of the VEA;

then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.

Schedule 1 - Dictionary  

Note:               See Section 6

1               Definitions

In this instrument:

                               dyslipidaemia means persistently abnormal blood lipid levels, diagnosed by a medical practitioner and evidenced by:

(a)          a serum high density lipoprotein cholesterol level less than 1.0 mmol/L; or

(b)          a serum low density lipoprotein level greater than 4.0 mmol/L; or

(c)           a serum triglyceride level greater than or equal to 2.0 mmol/L; or

(d)           a total serum cholesterol level greater than 5.5 mmol/L; or

(e)           the regular administration of drug therapy to normalise blood lipid levels.

                               episcleritis means acute or chronic inflammation of the superficial, episcleral layer of the eye ball.

                               equivalent glucocorticoid therapy means a glucocorticoid in the following table, at the doses specified in the table, or a therapeutically equivalent dose of another glucocorticoid:

                               equivalent inhaled glucocorticoid means:

(a)          8,000 micrograms of triamcinolone;

(b)          1,600 micrograms of budesonide;

(c)          1,000 micrograms of fluticasone; or

(d)          a therapeutically equivalent dose of another inhaled glucocorticoid.

                               glucocorticoid therapy as specified means:

(a)          taking:

(i)             hydrocortisone orally, by injection, or per rectum:

1. to a cumulative dose of at least 1,500 milligrams; and
2. at a minimum dose rate averaging 50 milligrams per day; or

(ii)          equivalent glucocorticoid therapy orally, by injection, or per rectum; or

(b)           inhaling at least 1,600 micrograms of beclomethasone, or equivalent inhaled glucocorticoid, daily for at least four weeks; or

(c)           using a topical ocular glucocorticoid to the affected eye daily for at least two weeks; or

(d)          using an intranasal glucocorticoid at above the maximum therapeutic dosage level daily for at least four weeks; or

(e)           having an intraocular or periocular glucocorticoid injection to the affected eye; or

(f)            applying a topical glucocorticoid to the face daily for at least four weeks; or

(g)           applying a high or very high potency topical glucocorticoid to at least 20% of total skin surface area, daily, for at least four weeks.

Note: equivalent glucocorticoid therapy, equivalent inhaled glucocorticoid and high or very high potency topical glucocorticoid are also defined in the Schedule 1 - Dictionary.

                               high or very high potency topical glucocorticoid means:

(a)          betamethasone dipropionate 0.05%;

(b)          betamethasone valerate 0.1%;

(c)          clobetasol proprionate 0.05%;

(d)          diflucortolone valerate 0.1%;

(e)          fluocinolone acetonide 0.025%; or

(f)           another topical glucocorticoid of equivalent potency.

                                MRCA means the Military Rehabilitation and Compensation Act 2004.

                               open-angle glaucoma—see subsection 7(2).

                               relevant service means:

(a)          operational service under the VEA;

(b)          peacekeeping service under the VEA;

(c)          hazardous service under the VEA;

(d)          British nuclear test defence service under the VEA;

(e)          warlike service under the MRCA; or

(f)           non-warlike service under the MRCA.

Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary.

                               scleritis means acute or chronic inflammation that affects the white outer coating of the eye ball.

                               specified list of conditions or procedures means:

(a)          carotid endarterectomy;

(b)          diabetic retinopathy;

(c)          intraocular surgery;

(d)          intraocular tumour;

(e)          carotid artery disease;

(f)           radiotherapy;

(g)          retinal detachment;

(h)          retinal vascular occlusion;

(i)            retinal vasculitis; or

(j)            another acquired condition causing posterior segment ischaemia.

                               specified list of endocrine diseases means:

(a)          Cushing syndrome;

(b)           diabetes mellitus;

(c)           eye disease associated with Graves' disease; and

(d)          hypothyroidism.

                               sympathetic ophthalmia means the presence of uveitis in both eyes following:

(a)          intraocular surgery to one eye; or

(b)          trauma to one eye.

Note: trauma is also defined in the Schedule 1 - Dictionary.

                               terminal event means the proximate or ultimate cause of death and includes the following:

(a)           pneumonia;

(b)           respiratory failure;

(c)           cardiac arrest;

(d)           circulatory failure; or

(e)           cessation of brain function.

                               trauma means:

(a)          blunt or penetrating physical injury; or

(b)          chemical, thermal or radiation injury;

                               that results in intraocular inflammation, intraocular bleeding or other intraocular tissue disruption.

                               uveitis means acute or chronic inflammation of the vascular middle coat of the eye ball, comprising the iris, ciliary body and choroid. This definition includes choroidal effusion.

                               VEA means the Veterans' Entitlements Act 1986.