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Glaucoma Dialogue IGR 12-4
Comments
Comment by Chris Leung on:
46501 Treating patients presenting with advanced glaucoma - Should we reconsider current practice?, King AJ; Stead RE; Rotchford AP, British Journal of Ophthalmology, 2011; 95: 1185-1192
See also comment(s) by Keith Barton • George Spaeth • Franz Grehn • Felipe Medeiros • Jeffrey Liebmann •Currently, most ophthalmologists treat patients starting with topical drop medication. In patients who continue to progress or in whom target intraocular pressure (IOP) is not achieved, surgical intervention is then offered. In this review article, King et al. examined evidence for using surgery, in contrast to glaucoma medications, as the primary management for patients with advanced glaucoma (defined by Hodapp's classification in the UK National Institute for Health and Clinical Excellence [NICE], as mean deviation (MD) from -12 dB to > -20 dB).
The review summarizes studies comparing medical versus surgical treatment, and discusses the outcomes according to IOP control, visual field progression, visual acuity loss, and health-related quality of life. Data from the Collaborative Initial Glaucoma Treatment Study (CIGTS), the Moorfields Glaucoma Trial, the Glasgow Trial, and the Moorfields Primary Treatment Trial suggested that patients presenting with more advanced disease may have better outcomes with surgery than medical treatment (lower IOP, but difference between groups reduced with time, lower diurnal IOP fluctuation, and slower visual field progression in the surgical group). Of note, in CIGTS, patients undergoing surgery lost more visual acuity compared to the medical group, and despite there was no difference between the two treatment groups for the total score of the visual activities questionnaire (VAQ), there was approximately 5% more dysfunction on the VAQ acuity subscale in the primary surgery cohort of CIGTS.
The UK NICE recently recommended that patients with advanced glaucoma should be offered primary surgery. King et al. rightly mentioned that, as none of these randomized clinical trials (RCTs) was specifically looking at patients with advanced glaucoma, the current NICE recommendation therefore was not yet supported by strong evidence. There is yet no solid ground for clinicians to adopt the recommendation by NICE of primary surgical interventions for advanced glaucoma.
In my opinion, auditing the clinical outcomes at a national level for this NICE recommendation will provide important insights, in addition to a RCT specifically for advanced open-angle glaucoma. In parts of the world where angle-closure glaucoma is prevalent, a separate RCT for advanced angle-closure glaucoma is relevant, since phacoemulsification alone may open up the angle and compared to trabeculectomy, may have the potential to be an effective, safer 'glaucoma' surgical intervention that enhances the quality of life of patients.1,2
References
- Lam DS, Leung DY, Tham CC, et al., Randomized trial of early phacoemulsification versus peripheral iridotomy to prevent intraocular pressure rise after acute primary angle closure. Ophthalmology 2008;115:1134-40.
- Tham CC, Kwong YY, Leung DY, et al., Phacoemulsification versus combined phacotrabeculectomy in medically uncontrolled chronic angle closure glaucoma with cataracts. Ophthalmology 2009;116:725-31.
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