Ординатура / Офтальмология / Английские материалы / Shields Textbook of Glaucoma, 6th edition_Allingham, Damji, Freedman_2010

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Shields > SECTION III - Management of Glaucoma >

27 - Principles of Medical Therapy and Management

Authors: Allingham, R. Rand

Title: Shields Textbook of Glaucoma, 6th Edition Copyright ©2011 Lippincott Williams & Wilkins

> Table of Contents > SECTION III - Management of Glaucoma > 27 - Principles of Medical Therapy and Management

27

Principles of Medical Therapy and Management

This chapter covers the management of the patient with glaucoma using an evidence-based approach. The following factors will be considered: (a) making an accurate clinical diagnosis; (b) assessing the stage of disease; (c) assessing the risk factors for disease progression; (d) understanding the patient's access to health care and related factors; (e) considering the patient's lifestyle, health status, and life expectancy; and (f) implementing a treatment strategy on the basis of these factors and other considerations. All of these factors influence how aggressive the physician should be to achieve the target intraocular pressure (IOP) range to minimize the progression of glaucomatous optic neuropathy. In addition, given the current resources for information and technology through the Internet, literature, glaucoma support groups, and other sources, patients are better informed today (although sometimes misinformed) about their glaucomatous conditions. It is essential to make the patient a part of the team in his or her care, which includes discussion of treatment options from medical to laser or surgical interventions.

GATHERING EVIDENCE TO EVALUATE THE PATIENT

After gathering the data on the patient and making the clinical diagnosis (as described in the preceding chapters), the physician must understand the evidence from the results of major epidemiology studies (see Chapter 9) and glaucoma clinical trials to develop a management plan for the individual patient. Four major prospective National Institutes of Health-sponsored glaucoma clinical trials have shown that lowering IOP is important for “protecting” the susc eptible optic nerve in patients with glaucoma (see Chapters 10 and 11, and the National Eye Institute's Web site: www.nei.nih.gov/neitrials/topics.asp#glau-coma). In addition, another glaucoma clinical trial reported on the benefit of reducing IOP in patients with normal-tension glaucoma (1). These large-scale randomized clinical trials were designed to study outcomes in a cohort of patients with different forms and stages of chronic open-angle glaucoma (COAG) or suspected glaucoma. Results of these studies can be used as we recommend management and treatment for the individual patient. The results are summarized below.

Ocular Hypertension Treatment Study

The Ocular Hypertension Treatment Study (OHTS) evaluated the safety and efficacy of topical ocular hypotensive medication in delaying or preventing the onset of COAG in participants with no initial glaucomatous damage and an IOP between 24 and 32 mm Hg (2, 3). An important aspect of the design of this study was to evaluate the risk for glaucoma in patients of both European ancestry and black African descent. The 1636 participants were randomly assigned to observation or treatment with a target IOP reduction of 20%. The investigators found that topical ocular hypotensive medications can delay the onset of COAG in patients with elevated IOP, although not all patients with ocular hypertension require treatment. In the multivariate analysis, race was not a significant risk factor, which can be explained by the fact that African Americans in OHTS had overall thinner central corneas and larger optic discs. The clinical risk factors that increased the risk for glaucoma included older age, large cup-to-disc ratio, early visual field loss, thin central cornea, and elevated IOP.

Early Manifest Glaucoma Trial

The Early Manifest Glaucoma Trial (EMGT) assessed treatment versus observation without treatment in patients with early glaucoma and found that progression was less frequent and occurred later in treated

patients (4, 5). The EMGT demonstrated that the following factors were predictors of glaucoma progression: elevated IOP, older age, bilaterality, exfoliation, disc hemorrhages, and relatively thin central cornea. In addition, lower systolic perfusion pressure, lower systolic blood pressure, and cardiovascular disease history emerged as new predictors, suggesting a vascular role in glaucoma progression (6).

Collaborative Initial Glaucoma Treatment Study

The Collaborative Initial Glaucoma Treatment Study (CIGTS) evaluated the efficacy and safety of surgery versus medical treatment in patients with newly diagnosed, early glaucoma and found similar outcomes with the two treatment approaches (7). Investigators also found that when patients receive a glaucoma diagnosis, they may have symptoms that are not elicited by routine clinical testing, requiring discussion with the patient to reduce worries and unnecessary concerns about blindness and improving their quality of life (8).

Advanced Glaucoma Intervention Study

The Advanced Glaucoma Intervention Study (AGIS) investigated two surgical sequences in patients with advanced glaucoma. One sequence began with argon laser trabeculoplasty followed by trabeculectomy, if necessary; the other began with trabeculectomy and was followed by argon laser trabeculoplasty followed by trabeculectomy, if necessary; the other began with trabeculectomy and was followed by argon laser trabeculoplasty

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if the trabeculectomy failed. The study provided a weak suggestion that an initial argon laser trabeculoplasty delays the progression of glaucoma more effectively in black patients than in white patients (9). Retrospective evaluation of the study data suggest that consistent, low IOPs with minimal IOP variation is associated with reduced progression of visual field in patients with advanced glaucoma (10).

APPROACH TO THE PATIENT WITH GLAUCOMA

These clinical trials and other evidence from epidemiology studies have led to a better understanding of the management of patients with ocular hypertension and with early and advanced glaucoma (11, 12). Given these evidence-based risk factors, it is important to consider that an individual patient may not be comparable with the study participants, who had to meet specific inclusion and exclusion criteria to be enrolled in the clinical trials. Thus, the recommendations to treat patients with various forms and disease stages of glaucoma should be guided by the results of these important clinical trials, while keeping in mind potential differences between the individual patient and the average clinical trial participant (13). Overall, when treating the individual patient, physicians should remember that IOP is a surrogate clinical endpoint and that the long-term goal is to preserve vision and the best quality of life for the patient. In the perspective of glaucoma and the vision spectrum (Fig. 27.1), our approach must change along the vision continuum to accommodate the knowledge gained from epidemiology studies, clinical trials, and long-term clinical experience.

research areas represented in the “ biologic networks” and “ environment.” (Modified from Moroi SE, Richards JE. Glaucoma and genomic medicine. Glaucoma Today. 2008;1: 16-24.)

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The New Patient

A new patient may or may not know whether he or she has glaucoma or know the type of glaucoma. If the patient has not been seen by an ophthalmologist previously, a full eye examination is indicated. This entails addressing the chief complaint; obtaining an ocular and medical history; testing visual acuity and refraction; performing tonometry and pachymetry; conducting an external examination with evaluation of the pupillary reaction, slitlamp biomicroscopy, and gonioscopy; assessing the retina and optic nerve head with photographic documentation; and testing the visual field.

When making a new diagnosis of glaucoma, physicians should explain the basics of glaucoma to the patient and help him or her understand that glaucoma can lead to irreversible blindness, but that this can be prevented with early diagnosis and proper care. It is also important to explain the type of glaucoma and to show the patient photographs of the optic disc or a computerized topographic analysis report and copies of the visual fields. It is worth explaining to patients that, unless the glaucoma is diagnosed in the very advanced stage, the prognosis for retaining their vision is excellent, especially with a good understanding of their disease combined with adherence to recommended treatment and frequent followup visits. In one study, white patients with glaucoma had an approximately 25% chance of monocular blindness and a 9% chance of bilateral blindness in 20 years, even if the glaucoma remained uncontrolled (14).

The Established Patient

For the established patient, the critical components of continuity of care are to evaluate adherence to glaucoma medical treatment, evaluate tolerance to the treatment, and assess stability of the optic nerve head and visual function. If the patient has had a surgical intervention, the surgical site should be examined carefully for signs of tissue breakdown or infection. Many patients are more interested in their IOP levels, often remembering the numbers from the previous visit. Although sharing this information with the patient is helpful, a discussion of the complete clinical picture allows the patient to be better educated, which may result in better adherence to the treatment plan.

THE TREATMENT PLAN

In general, the overall goal to managing all patients with glaucoma is to preserve visual function while maintaining the best possible quality of life. This goal can be achieved by preventing or slowing the progression of glaucomatous damage by lowering IOP to a level at which further damage is minimal. Although not universally accepted, guidelines for glaucoma treatment are available from various professional societies (e.g., American Academy of Ophthalmology, at http://one.aao.org/CE/PracticeGuidelines/PPP.aspx; International Council of Ophthalmology, at www.icoph.org; European Glaucoma Society, at www.eugs.org; and South East Asia Glaucoma Interest Group, at http://seagig.org), with approaches for managing the various clinical forms of glaucoma or ocular hypertension. In the medical management of a patient with glaucoma, physicians should consider when to initiate treatment, how to start, how to follow the patient, when to change the treatment, and when to move on to surgical intervention.

When to Treat

To avoid unnecessary treatment, physicians must decide whether treatment is really indicated. When elevated IOP is present without glaucomatous damage (i.e., ocular hypertension), the physician must evaluate the risk factors for progression to glaucoma before deciding whether to treat. Most patients who have ocular hypertension appear to do well without treatment (2). When the patient presents with established glaucomatous damage or dangerously high IOP, the indication to initiate treatment is usually clear.

How to Start

Initiating treatment involves establishing the target IOP or IOP range, selecting the appropriate medication, educating and instructing the patient, and establishing the efficacy and safety of the