terminology and guidelines for glaucoma ii - Kwaliteitskoepel

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$Refractiechirurgie - Nederlands Oogheelkundig Gezelschap$

II - RANDOMIZED CONTROLLED TRIALS FOR GLAUCOMA Since the first edition of the Guidelines the results from several large randomized controlled trials have been available. These trials addressed the effect of IOP lowering treatment in glaucoma have been published. Until these results, there was no scientific evidence that treament for glaucoma had any effect in decreasing visual loss from the disease. Many of the clinical recommendations given then are now reinforced by these results. Whilst a proportion of the recommendations and definitions in the second edition are still derived from common practice and consensus, it is now relevant to see how daily management of our patients can be helped by the findings of these studies. In the following pages we list each with a summary of their layout and results, outline strengths and weaknesses, and derive comments relevant to clinical decision making. II.1 - THE OCULAR HYPERTENSION TREATMENT STUDY (OHTS) Multicentre, prospective study on patients with a normal ocular examination, except for elevated IOP between 24 and 32 mmHg in one eye and between 21 and 32 mmHg in the other eye. The purpose was to study differences in conversion rate to POAG between the natural history (No Rx) versus treatment (IOP lowering Rx) in patients with elevated IOP (OH). To be eligible for recruitment, repeated VF and both clinical and stereophotography evaluations of the optic disc had to be assessed as normal by a reading center. VA had to be at least 20/40 in either eye. A total of 1636 patients between 40 to 80 years were recruited. Randomization was between treatment with IOP lowering medications and no treatment. The treatment goal was to lower the IOP to < 24mmHg and at least 20% from baseline, unless it was already 90%) did not convert to POAG over time. Endpoints for POAG conversion were reached by both disc and VF findings in up to 10% of the cases, by disc only in around 50% and by VF only in roughly 40% of the total, without significant diferences between treated and control cases 2 . Among medication effects, 17% of those treated with a prostaglandin analogue showed iris or eyelash changes, versus 7.6% of those treated with other drugs (p < 0.001). Cataract formation was more in the medication group (6.4 vs 4.3 %; p 588, between 588 and 555 and < than 555 micron respectively), those with thinner corneas had an hazard risk ratio of 3.9 compared to the thickest ones. The same higher risk for patients with thinner corneas was found when multivariate analysis was performed across the spectrum of IOP groups and cup-to-disc ratios. According to these results, CCT-corrected tonometry readings are valuable when IOP measurements are high and treatment is being considered, since they will uncover falsely high readings caused by thick corneas 4 . - Strengths Large sample size Careful follow-up Masked assessment of endpoints Attribution of endpoints by a masked committee Ch. Intro 5 EGS
Inclusion of all commercially available drugs Careful quality control and feedback to technicians and photographers True-incidence cases -Weaknesses Limited IOP range, i.e. no information on higher or lower IOPs than the selection criteria Sample is from healthy volunteers and not population based Relatively small number of POAG endpoints Limited to patients with reliable visual fields High thresholds for endpoints Some risk factors under-represented Criteria for conversion to POAG adjusted during study If a correction factor was applied at baseline for CCT, up to 57% of white subjects and up to 37 % of black subjects would have corrected IOPs. If such an adjustment had been made at baseline some would not have had OH. Some of the patients with normal white-on-white perimetry were later reported (ARVO 2002) to have had SWAP defects at baseline, thereby casting doubt on the “normal” state of some of the participants. II.2 - COLLABORATIVE INITIAL GLAUCOMA TREATMENT STUDY (CIGTS) Randomized clinical trial on 607 patients with newly diagnosed open-angle glaucoma Initial treatment was either medication or trabeculectomy (with or without 5-fluorouracil) A target IOP algorithm was used to guide the IOP lowering treatment. Patients were treated as aggressively as needed in an effort to reduce IOP to a level at or below a predetermined target pressure specific for each individual eye Primary outcome variables were VF loss and Quality of Life (QoL). Secondary outcome variables were Visual Acuity (VA) IOP, Cataract formation. Inclusion criteria were: (a) IOP 20 mmHg or higher with Humphrey visual field defect of at least three contiguous points and an optic disc which was considered compatible with glaucoma, or (b) IOP of 20 - 26 mmHg with two contiguous defect points in the visual field, or (c) an IOP of 27 mmHg and higher without visual field damage and suspected glaucomatous disc. Summary of results 5 On the basis of completed follow-up through 4 years and partially completed through 5 years, VF progression did not differ significantly by initial treatments. IOP was lower with surgery (average 14-15 mmHg) than with medications (average 17-18 mmHg), decreasing 35% with medications and 48% with surgery. Perimetry results were equal and MD remained stabile in both groups. QoL was initailly better with drugs (mostly betablockers) Both medications and surgery increased the incidence of cataract extraction (6% vs 17%). Medical treatment (including cross-over) reduced IOP from 27 to 17 mmHg i.e. 10 mmHg or 37%. VA decreased initially more in the surgical group: it was equal at the end of follow-up. ALT lowered the IOP after both medications and surgery. - Strengths Individualized target IOP approach Newly diagnosed patients QoL prospectively addressed - Weaknesses Inclusion criteria may have allowed recruitment of OH resulting in a case mix with little risk of showing progression Sequence of treatment steps and cross over not clearly understandable Initial trabeculectomy was sometimes supplemented with 5-FU Follow up might not be long enough to show differences Ch. Intro 6 EGS
Page 2 and 3: ISBN: 88-87434-13-1 Editrice DOGMA
Page 4 and 5: ACKNOWLEDGEMENT This work was made
Page 6 and 7: 2.2.5 - Primary Open-Angle Glaucoma
Page 8 and 9: Foreword These Definitions and Guid
Page 10 and 11: INTRODUCTION The aim of the book is
Page 12 and 13: Since resources are limited worldwi
Page 16 and 17: II.3 - COLLABORATIVE NORMAL TENSION
Page 18 and 19: No stratification for stage of dise
Page 20 and 21: II. 6. 3 - from CNTG 1. Therapy tha
Page 22 and 23: References 1) The Ocular Hypertensi
Page 24 and 25: I - QUESTIONS TO ASK TO YOUR GLAUCO
Page 26 and 27: III - ABNORMAL THRESHOLD VISUAL FIE
Page 28 and 29: V - GONIOSCOPIC OPEN ANGLES SOME DI
Page 30 and 31: VII - TREATMENT STEPLADDER JUVENILE
Page 32 and 33: IX - MONOTHERAPY (in alphabetic ord
Page 34 and 35: XI - MANAGEMENT ACUTE ANGLE CLOSURE
Page 36 and 37: XIII - ANTIMETABOLITES FOR WOUND MO
Page 38 and 39: CHAPTER 1 PATIENT EXAMINATION
Page 40 and 41: Other methods 22-25 : Air-puff tono
Page 42 and 43: References 1) Martin XD. Normal int
Page 44 and 45: 1.2 - GONIOSCOPY Gonioscopy is a fu
Page 46 and 47: 1 2 3 4 Fig. 1 Dynamic indentation
Page 48 and 49: The Spaeth classification Insertion
Page 50 and 51: References 1) Palmberg P. Gonioscop
Page 52 and 53: small - size mid - size large - siz
Page 54 and 55: Fig. 5 A) Cirumlinear vessel, B) Ba
Page 56 and 57: 1.3.4.3 - OCT The Optical Coherence
Page 58 and 59: 31) Carpineto P, Ciancaglini M, Zup
Page 60 and 61: central 24 or 30 central degrees re
Page 62 and 63: A retinal sensitivity value worse t
Page 64 and 65:
HODAPP CLASSIFICATION 31 EARLY GLAU
Page 66 and 67:
References 1) Bengtsson B, Heijl A,
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1.5 - BLOOD FLOW 1.5.1 - VASCULAR F
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28) Flammer J, Orgul S, Costa VP, O
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All forms of glaucoma should be cla
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2.2 - PRIMARY OPEN-ANGLE GLAUCOMAS
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2.2.4 - PRIMARY OPEN-ANGLE GLAUCOMA
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2.3 - SECONDARY OPEN-ANGLE GLAUCOMA
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2.3.1.6 - Glaucoma due to intraocul
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2.4 - PRIMARY ANGLE-CLOSURE Primary
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Systemic Risk factors for primary a
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OCCLUDABLE ANGLE: “Occludable”
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2.5.3 - SECONDARY ANGLE-CLOSURE GLA
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CHAPTER 3 TREATMENT PRINCIPLES and
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Furthermore, blindness may occur de
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T A R G E T I O P Target IOP range
Page 96 and 97:
Practical points for topical medica
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3.3.1.1 - Category: ADRENERGIC AGON
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3.3.1.2 - Category: ADRENERGIC ANTA
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3.3.1.3 - Category: CARBONIC ANHYDR
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3.3.1.4 - Category: PARASYMPATHOMIM
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3.3.1.5 - Category: PROSTAGLANDIN D
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Drug interactions Precipitation occ
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COMBINATION THERAPY Starting* Addit
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3.3.2.2 - Category: ADRENERGIC ANTA
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Pregnancy and nursing mothers Only
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3.5 - LASER SURGERY 3.5.1 - LASER I
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3.5.2 - LASER TRABECULOPLASTY 77-89
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3.5.4 - CYCLOPHOTOCOAGULATION Indic
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Although medical therapy is still t
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3.6.4 - COMPLEX CASES Complicated g
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Post-operative use Concentration: 0
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25) Janz NK, Wren PA, Lichter PR, M
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(Rescula TM ) in patients with glau
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in white patients with open-angle g
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CHAPTER 4 TREATMENT GUIDELINES
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4.2 - PRIMARY OPEN-ANGLE GLAUCOMAS
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4.2.7 - OCULAR HYPERTENSION (OH) Al
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4.3.1.7 - Glaucoma associated with
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• Withdrawal of aqueous from vitr
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4.5 - SECONDARY ANGLE-CLOSURE GLAUC
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4.5.3 - SECONDARY ANGLE-CLOSURE GLA
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NOTES
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NOTES
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NOTES
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