Canadian Ophthalmological
Society
Evidence-based Clinical Practice
Guidelines for the Management of
Glaucoma in the Adult Eye
Glaucoma Therapies
Overarching and specific
management goals
•
•
•
•
Preserve visual function.
Maintain or enhance overall health-related QOL.
Slow or halt progression of the disease.
Achieved through a careful process of:
– observing and monitoring visual function,
– providing patient education and support,
– providing medical, laser, and (or) surgical intervention
as appropriate, and
– observation without treatment in some cases.
Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Quality-of-life considerations
• Glaucomatous field damage adversely affects the
patient’s QOL.1,2
• Patients with glaucoma report:
– Difficulties with bright lights and with light and dark
adaptation.3
– Worry or concern about the possibility of blindness.
– Difficulty with mobility (falls and motor vehicle accidents).1,4
– A negative impact associated with the therapy itself.
1. Noe G, et al. Clin Experiment Ophthalmol 2003;31:482–6.
2. Altangerel U, et al. Curr Opin Ophthalmol 2003;14:100–5.
Canadian Ophthalmological Society evidence-based clinical
3. Janz NK, et al. Ophthalmology 2001;108:887–97.
practice guidelines for the management of glaucoma in the
4 .Haymes SA, et al. Invest Ophthalmol Vis Sci
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
2007;48:1149–55.
Overall and specific management
goals in patients with glaucoma
• Preserve visual function by slowing or halting progression
of disease
• Maintain or enhance health-related QOL
Specific goals • Set individualized target IOP for each eye
• Observation or IOP lowering to achieve target IOP with
one or more of medicine, laser, surgery
• Minimize the side effects of treatment and its impact on
the patient’s vision, general health, and QOL
• Reverse or prevent angle closure process if applicable
• Preserve the structure and function of the optic nerve
• Vision enhancement/rehabilitation as indicated
• Educate and empower patients so they are active
participants in their vision health
• Achieve sustainable cost for the patient
• Optimal utilization of human, information technology, and
other resources
Overall goals
Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Lowering IOP and
Setting Target IOP
Lowering IOP
• IOP lowering is the only clinically established
method of treating glaucoma.
• The effectiveness of IOP lowering has been
established in several well-designed prospective
RCTs.1-4
1. AGIS Investigators. Am J Ophthalmol 2000;130:429–40.
2. Collaborative Normal-Tension Glaucoma Study Group.
Canadian Ophthalmological Society evidence-based clinical
Am J Ophthalmol 1998;126:487–97.
practice guidelines for the management of glaucoma in the
3. Heijl A, et al. Arch Ophthalmol 2002;120:1268–79.
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
4. Chauhan BC, et al. Arch Ophthalmol 2008;126:1030–6.
Lowering IOP (cont’d)
• Reducing fluctuation in IOP (diurnal and (or)
intervisit) may also be a worthwhile objective in
select patients, such as those with:
– advanced glaucoma, or
– disease progression despite seemingly good
IOP control, and
– PXF glaucoma.1,2
1. AGIS Investigators. Am J Ophthalmol
2000;130:429–40.
2. Asrani S, et al. J Glaucoma 2000;9:134–42.
Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Setting target IOP
• Formulation of target IOP is one of the most
important steps in treatment.
• Target IOP is defined as the upper limit of a
stable range of measured IOPs deemed likely
to retard further optic nerve damage.1
1.
American Academy of Ophthalmology. Primary
Canadian Ophthalmological Society evidence-based clinical
Open-Angle Glaucoma. Preferred Practice
Pattern. San Francisco, CA: American Academy practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
of Ophthalmology; 2005.
Setting target IOP (cont’d)
• When setting target IOP, each eye is staged into 1 of 4 severity
groups — suspect, early, moderate, or advanced glaucoma —
based on:
–
–
–
–
–
–
–
assessment of the optic nerve and (or) VF
patient factors
age
life expectancy
QOL
risk factors for progression
patient’s own input
• There is a fine line between setting an appropriate goal to prevent
optic nerve damage, and being overly aggressive in IOP lowering.
Canadian Ophthalmological Society evidence-based clinical practice
guidelines for the management of glaucoma in the adult eye. Can J
Ophthalmol 2009;44(Suppl 1):S1S93.
Staging each eye for
glaucoma damage
Suspect
One or two of the following: IOP >21 mm Hg; suspicious disc
or C/D asymmetry of >0.2; suspicious 24-2 (or similar) VF
defect
Early
Early glaucomatous disc features (e.g., C/D* <0.65) and (or)
mild VF defect not within 10° of fixation (e.g., MD better than
–6 dB on HVF 24-2)
Moderate Moderate glaucomatous disc features (e.g., vertical C/D*
0.7–0.85) and (or) moderate VF defect not within 10° of
fixation (e.g., MD from –6 to –12 dB on HVF 24-2)
Advanced Advanced glaucomatous disc features (e.g., C/D* >0.9) and
(or) VF defect within 10° of fixation† (e.g., MD worse than –12
dB on HVF 24-2)
Adapted from Damji KF, et al. Can J Ophthalmol 2003;38:189–97.
*Refers to vertical C/D ratio in an average size nerve. If the nerve is small, then a smaller C/D ratio
may still be significant; conversely, a large nerve may have a large vertical C/D ratio and still be
within normal limits.
†Also consider baseline 10-2 VF (or similar).
Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Suggested upper limit of initial
target IOP for each eye
Stage
Suspect in whom a
clinical decision is
made to treat
Early
Moderate
Advanced
Suggested upper limit of target IOP.
Modify based on longevity, QOL and
risk factors for progression
24 mm Hg with at least 20% reduction
from baseline
Evidence
20 mm Hg with at least 25% reduction
from baseline
17 mm Hg with at least 30% reduction
from baseline
14 mm Hg with at least 30% reduction
from baseline
EMGTS
CIGTS
CNTGS
AGIS
AGIS
Odberg
OHTS
EGPS
Adapted from Damji KF, et al. Can J Ophthalmol 2003;38:189–97.
Note: Target IOP may need to be adjusted during the course of follow-up. Extremes of CCT may
be helpful in the setting of target IOP. For example, if the cornea is very thin, this may encourage a
more aggressive approach with more frequent follow-up.
Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Staging severity of glaucoma
Recommendation
Stage each eye of the patient as normal, suspect,
early, moderate or advanced glaucoma based on
optic nerve and (or) VF exam [Consensus].
Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Target IOP — setting initial range
Recommendation
Set upper limit of initial target IOP range for each
eye at first visit and then re-evaluate at each visit
based on stability/change in structure and function
of the optic nerve (i.e., ONH exam with or without
additional imaging information as well as VF data)
[Consensus].
Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.