terminology and guidelines for glaucoma ii - Kwaliteitskoepel

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$Refractiechirurgie - Nederlands Oogheelkundig Gezelschap$

II.3 - COLLABORATIVE NORMAL TENSION GLAUCOMA STUDY (CNTG study) Multicentre prospective randomized trial comparing treatment versus no treatment in Normal Tension Glaucoma. The primary outcome measure was disease progression. To be considered for the study, patients had to have glaucomatous optic disc abnormalities and visual field defects according to standardized criteria 6 , with no recorded IOP > 24 mmHg in either eye. After a 1 month wash out period and 10 baseline IOP readings (6 of them between 8 A.M and 6 P.M) the median IOP had to be 20 mmHg or less, with a maximum of one peak of up to 24 mm Hg. At least three reliable baseline visual fields (Octopus 32 or Humphrey 30-2) and at least 20/30 BCVA were required. Cases with far advanced damage, defined as less than 9 residual adjacent points measurable with stimulus size 3, were excluded. Ages ranged from 20 to 90 years.The follow up was every 3 months during the first year and and every 6 months thereafter. VF progression had to be verified on two or three fields performed within 1 month and confirmed in two or three fields done 3 months later 6 . Optic disc progression was confirmed by reading masked sets of stereo disk photographs. Randomization. If the visual field defect threatened fixation or progression was documented i.e: recent VF progression, change in the optic nerve head appearance or disk haemorrhage patients were randomized to either IOP lowering treatment or as controls. A total of 140 eyes of 140 patients were randomized. Goal of the treament was a 30 % reduction from average of 3 baseline IOP readings, obtained with medications, excluding beta blockers and adrenergic agents, with laser trabeculoplasty or trabeculectomy, progressively stepped up to achieve the IOP goal. In patients undergoing surgery a 20% reduction was allowed without requiring repeated surgery. Summary of results 7,8 Treatment group: 61 eyes. At randomization the IOP was 16.1 +/- 2.3 mm Hg, during FU 10.6 +/- 2.7 mm Hg (p
II.4 - THE ADVANCED GLAUCOMA INTERVENTION STUDY (AGIS) Multicentre, prospective randomized study on advanced open-angle glaucoma patients who suffer from glaucoma that cannot be controlled by maximum tolerated medical therapy alone. The 591 patients of 35 to 80 years of age (789 eyes) were randomised between two treatment sequences for further interventions: argon laser trabeculoplasty → trabeculectomy → trabeculectomy (ATT) and trabeculectomy → argon laser trabeculoplasty → trabeculectomy (TAT). The second and third interventions were offered only after failure of the first and second interventions, respectively. The eyes enrolled had to be phakic, show a consistent elevation of intraocular pressure (IOP) of 18 mm Hg or greater, a reproducible, glaucoma-type visual field defect quantified using a custom made score system, as well as a minimum visual acuity equivalent with a Snellen value of >20/80. Patients with a MD worse than 16 db were excluded. Most of the patients were either Caucasian (325 eyes of 249 patients) or Afro-American (451 eyes of 332 patients). The study design, the patient characteristics and the results are so far published in nine different articles. Using 6-month visit intervals the follow-up time in these articles varies between 4 and 7 years. Summary of results Relationship between IOP and progression of the visual field damage over at least 6-years follow-up 9 . Predictive Analysis: eyes with average IOP greater than 17.5 mm Hg over the first three 6-months visits showed a significantly greater visual field deterioration compared to the eyes with IOP less than 14 mm Hg in the same time period. The amount of deterioration was greater at 7 years than at 2 years, i.e. increased with longer follow-up time. Associative Analysis: eyes with IOP less than 18 mm Hg at 100% of the visits over 6 years did not show an increase of their initial visual field defect, whereas eyes that reached this value only at 75 to 100 %, 50 to 75 % or 0 to 50 % of the visits all showed a significant increase of the visual field defect. The amount of visual field decrease was greater at 7 years than at 2 years. These results indicate that low IOP and low IOP fluctuation are associated with reduced progression of a visual field defect in advanced glaucoma. Patients with the lowest range of IOP (max 18mmHg) were the only ones showing overall stability of average VF scores; this effect was well separated from the other groups only after the fifth year of follow-up. In this same group, 14.4 % of the patients showed worsening, and 18% an improvement of four of more units compared to baseline. Relationship between treatment type and visual acuity /visual field preservation 10 : For a 7-year follow-up mean decrease of IOP was greater for eyes assigned to TAT, and the cumulative probability of failure of the first intervention was greater for eyes assigned to ATT. In Afro-American patients average percent of eyes with decreased visual acuity and visual field were less for the ATT sequence than for TAT. In Caucasians those were more favourable for ATT in the first 4 years, but then switched in favour of TAT. These results show that TAT sequence (trabeculectomy first) is recommended for Caucasians while ATT (laser trabeculoplasty first) is more favourable for the Afro-Americans. Adjustment for cataract progression 11 did not influence these results. Of course in clinical practice the choice must be individually adjusted to the patient characteristics and needs. Risk of cataract formation after trabeculectomy 12 : The expected 5-year cumulative probability of cataract formation was significantly increased by the first trabeculectomy whether it was the first or the second intervention. Diabetes mellitus and higher age at the study entry were also risk factors. The of overall risk of cataract was 78 %. Complications of trabeculectomy (particularly marked inflammation and flat anterior chamber) increased this risk to 104% compared to uncomplicated first trabeculectomy (47%). Racial difference in glaucoma progression after trabeculectomy 13 : Initial trabeculectomy retarded the progression of glaucoma more effectively in Caucasians than in Afro-Americans. Some patients continued to progress despite low IOPs; some patients retained high IOPs despite multiple interventions. - Strengths Long follow-up Large sample Standardized protocols Elgibility measurements were separated from baseline measurements - Weaknesses The Predictive and Associative analyses were post-hoc Only one visual field was used as baseline Limited range of IOP during follow up Ch. Intro 8 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 14 and 15: II - RANDOMIZED CONTROLLED TRIALS F
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,
Page 68 and 69:
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
Page 78 and 79:
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
Page 94 and 95:
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
Page 134 and 135:
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
Page 146 and 147:
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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