Canadian Ophthalmological
Society
Evidence-based Clinical Practice
Guidelines for the Management of
Glaucoma in the Adult Eye
Open-angle Glaucoma:
Primary Open-Angle
Glaucoma Suspects
Glaucoma suspects —
risk factor monitoring
Recommendation
A glaucoma suspect with any number of wellestablished risk factors should be monitored for
the development of glaucoma [Level 11].
1. Gordon MA, et al. Arch Ophthalmol
2002;120:714–20.
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.
Normal Pressure Glaucoma
Normal pressure glaucoma
(or POAG at normal IOPs)
• IOP associated with POAG is usually elevated
above the normal distribution (i.e. >21 mm Hg).
• However, when the IOP is not elevated, it is
often referred to as normal tension glaucoma or
NPG.
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.
Normal pressure glaucoma
(or POAG at normal IOPs)
• The pathogenesis of NPG remains controversial,
but it is:
– associated with a higher prevalence of vascular
disease and migraine,
– more common in older individuals, especially those
over age 55 years,
– more common in women than in men,1 and
– more common in the Japanese population compared
with other ethnic groups.2
1. Collaborative Normal-Tension Glaucoma
Canadian Ophthalmological Society evidence-based clinical
Study Group. Am J Ophthalmol 1998;126:487–97.
practice guidelines for the management of glaucoma in the
2. Shiose Y, et al. Jpn J Ophthalmol 1991;35:133–55.
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Natural history of NPG
• The natural history of NPG was evaluated in the CNTGS
during the time interval before randomization and in
those patients assigned to not receive treatment.1
• Approximately one-third of untreated patients showed
confirmed localized VF progression at 3 years.
• Approximately one-half showed further deterioration at
7 years.
• The change was typically small and slow, often
insufficient to measurably affect the mean deviation
index.
1. Collaborative Normal-Tension Glaucoma
Study Group. Am J Ophthalmol 1998;126:487–97.
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.
Natural history of NPG (cont’d)
• There was tremendous variability in progression rates,
with women and individuals with higher IOP, migraines or
disc hemorrhages having a greater risk of progression.1
• Overall, a 30% reduction in IOP was effective in reducing
the progression in a greater proportion of patients,
compared with those receiving no treatment.
• While 35% of the control group progressed compared
with 12% of the treatment group, it would hold that 65%
of the untreated group did not progress during the study
period.
1. Collaborative Normal-Tension Glaucoma
Study Group. Am J Ophthalmol 1998;126:487–97.
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.
NPG and treatment
Recommendation
NPG is a diagnosis of exclusion and therapy does
not need to be initiated unless there are significant
risk factors and signs of progression, or if fixation
is threatened at diagnosis [Level 11].
1. Anderson DR, et al. Ophthalmology
2001;108:247–53.
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.
Pigmentary Glaucoma
Pigmentary glaucoma
• Pigmentary glaucoma is a secondary form of
open-angle glaucoma produced by pigment
dispersion in the anterior segment of the eye.
• It constitutes 1% of the glaucomas seen in
many Western countries.
• There is a strong association between
pigmentary glaucoma and moderate myopia.
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.
Pigmentary glaucoma (cont’d)
• Features of pigmentary glaucoma consist of:
– a rise of IOP with optic nerve damage and/or VF loss,
and characteristics of pigment dispersion.
– There might be:
• anisocoria and heterochromia in the affected eye,
• lattice degeneration of the retina, with clumps of
pigment scattered at the base of the lattice,
• retinal pigment epithelial dysfunction,
• increased risk of retinal detachment (in up to 6% of
patients with pigment dispersion).1
1. Greenstein VC, et al. Arch Ophthalmol
2001;119:1291–5.
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.
Pigmentary glaucoma (cont’d)
• The probability of converting from pigment
dispersion to pigmentary glaucoma is fairly low
(10% at 5 years and 14% at 15 years).1
• The major risk factor for developing glaucoma is
an initial IOP of ≥21 mm Hg at presentation.
1. Siddiqui Y, et al. Am J Ophthalmol
2003;135:794–9.
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.
Treatment of
pigmentary glaucoma
• Medical, laser, and surgical options are similar to
those used to treat POAG.
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.
Laser iridotomy and
pigmentary glaucoma
Recommendation
It is recommended that laser iridotomy not be
routinely employed in the management of
pigmentary glaucoma [Level 21,2].
1. Reistsad CE, et al. J Glaucoma 2005;14:255–59. Canadian Ophthalmological Society evidence-based clinical
2. Gandolfi SA, et al. Ophthalmology 1996;
practice guidelines for the management of glaucoma in the
103:1693–5.
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Laser trabeculoplasty —
IOP monitoring
Recommendation
It is recommended that IOPs be checked within a
few hours post-laser trabeculoplasty, especially in
the presence of pigment dispersion because of the
higher risk of IOP spikes [Level 11].
1. Glaucoma Laser Trial Research Group.
Arch Ophthalmol 1989;107:1135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.
Pseudoexfoliation Syndrome
and Glaucoma
PXF syndrome and glaucoma
• PXF syndrome:
– Is the most common identifiable cause of open-angle
glaucoma worldwide.1
– Is a disease of elastic tissue in the posterior chamber of
the eye and other systemic sites.2
– Is more common in older age groups, with most cases
occurring in people in their late 60s and early 70s.3
– May be unilateral or bilateral at presentation, and many
unilateral cases become bilateral with time.
– Is more prevalent in Eastern Mediterranean and Northern
European countries.
1. Ritch R. Trans Am Ophthalmol Soc 1994;92:845–944.
2. Ritch R, et al. Prog Retin Eye Res 2003;22:253–75.
3. Conway RM, et al. Clin Experiment Ophthalmol
2004;32:199–210.
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.
PXF syndrome and glaucoma
• When PXF is accompanied by elevated IOP and
VF and/or disc damage, it is termed PXF
glaucoma.
• The percentage of PXF patients with glaucoma
is different for every population.
• About 25% of persons with PXF have elevated
IOP, and one-third of these have glaucoma.1,2
1. Ritch R, et al. Surv Ophthalmol 2001;45:265–315. Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
2. Conway RM, et al. Clin Experiment Ophthalmol
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
2004;32:199–210.
PXF syndrome and treatment
Recommendation
Close monitoring and aggressive IOP-lowering
therapy are indicated in patients with PXF
glaucoma due to their greater tendency to present
IOP spikes, greater 24-hour IOP fluctuations, and
their relatively worse prognosis compared with
patients with POAG [Level 21].
1. Leske MC, et al. Ophthalmology
2007;114:1965–72.
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.