I. Glaucoma Definitions
A. Primary Open Angle
B. Secondary Open Angle
C. Angle Recession
D. Normal Tension
E. Ocular Hypertension
II. How Do We Diagnose Glaucoma?
A. Optic Nerve Changes
B. Nerve fiber defects
C. Disc Hemorrhages
D. Visual Field Changes
III. How do we treat glaucoma?
A. Outflow medications
B. Aqueous Production Medications
C. Laser Trabeculoplasty
D. Trabeculectomy
E. Tube Filters
IV. Neuroprotection?
V. The Ocular Hypertension Treatment Study
A. Patient demographics
B. Treatment Group
1. 20% lowering
2. Maximum IOP of 24 mmHg
C. Observation Group
D. Primary Outcomes
1. Reproducible visual field abnormality
2. Optic Disc deterioration
E. Visual Field Outcomes
F. Optic Nerve Outcomes
G. Follow-Up
1. Median duration of follow-up 72 months for African Americans
2. Median duration of follow-up 78 months for all patients
3. Compliance 90%
H. IOP and Topical Medications
1. Target met in 87% of follow-up visits
2. At 5 years, 39% on two or meds
3. Three or more meds 9.3%
4. African Americans on at least two meds 44.5%
I. Reaching the outcome
1. Cumulative probability of developing OAG in observation group 9.5% at 5
years
2. Cumulative probability of developing OAG in treatment group 4.4% at 5
years
VI. So What Ocular Hypertensives Should We Treat?
A. Univariate Analysis
1. Older age
2. African American
3. Men
4. Higher IOP
5. Thin cornea
6. Vertical C/D enlargement
7. Horizontal C/D enlargement
8. Greater PSD
9. Heart Disease
B. Multivariate Analysis
1. Older Age
2. Higher IOP
3. Greater PSD
4. Larger Vertical C/D
5. Thinner Cornea
VII. Open Angle Glaucoma: Definition
VIII. Do We Need to Treat POAG? The Early Manifest Glaucoma Trial
A. Patient demographics
B. Treatment group
1. Pre-Tx IOP: 20.6 mmHg
2. Argon laser trabeculoplasty
3. Betaxolol 0.5% bid
4. Mean Post-Tx IOP: 15.5% (25% lowering)
C. Control group
1. Mean IOP 20.9 mmHg
D. Primary outcomes
1. Progression from baseline visual fields
2. Progression of optic nerves
E. EMGT Results
1. Observation Group: 62% progression of optic nerve or visual fields
2. Treatment Group: 45% progression of optic nerve or visual fields
3. Median survival time of treatment group was 18 months longer than
observation group
F. EMGT: Factors that predicted progression
1. Level of IOP reduction
2. Higher Pre-Tx IOP
3. Pseudoexfoliative material
4. Older age
5. Disc hemorrhage
IX. Does it matter how we lower the IOP? The Collaborative Initial Glaucoma
Treatment Study
A. Patient Demographics
B. Surgical Treatment Sequence
1. Trabeculectomy-ALT-Meds-Trabeculectomy-Meds
C. Medication Treatment Sequence
1. Meds-ALT-Trabeculectomy-Meds-Trabeculectomy-Meds
D. Primary Outcome
1. Advancement of visual field defects
E. CIGTS: Results
1. After two years, no significant difference in visual fields
2. Higher % of cataracts in surgical group
3. No significant difference in overall visual acuity
4. Higher % of severe vision loss in surgical vs. medical group
X. How much should we lower the IOP? The Advanced Glaucoma Intervention Study
A. Patient demographics
B. The treatment groups
1. ALT-Trabeculectomy-Trabeculectomy
2. Trabeculectomy-ALT-Trabeculectomy
3. Surgical interventions supplemented with medical therapy
4. Goal of reaching 18 mmHg
C. AGIS Outcomes: Progression of visual field in relation to different IOP parameters
D. The AGIS Predictive Analysis: Initial IOP lowering
1. Group A
<14 mmHg
2. Group B
14-17.5 mmHg
3. Group C
>17 .5 mmHg
E. Visual Field progression outcomes
F. The AGIS Associative Analysis: Extent of IOP lowering
1. Group A
100% under 18 mmHg
2. Group B
75-100 % under 18 mmHg
3. Group C
50-75% under 18 mmHg
4. Group D
0-50% under 18 mmHg
G. Visual Field Progression Outcomes
XI. What about when the pressure is low? The Collaborative Normal Tension
Glaucoma Study
A. Patient demographics
B. Treatment Group
1. 30% IOP lowering by surgical or medical therapies
2. No more than 3 total surgical procedures
C. Observation group
D. Primary outcomes
1. Visual field progression
2. Optic nerve progression
3. Optic disc hemorrhage
E. NTGS Results
1. Untreated controls progressed 35%
2. Treated patients that progressed 12%
3. Median survival time for treatment group: 2,688 days
4. Median survival time for control group: 1,695 days
5. Race variability in survival times
a. Asian American
2527 days
b. Caucasian
1985 days
c. African American
1282 days
6. Sex variability in survival times
a. Women
1849 days
b. Men
2356 days
7. Presence of Migraine and survival times
a. History of Migraine
1212 days
b. No History of Migraine
2142 days
8. Presence of disc hemorrhage and survival times
a. Disc hemorrhage
1187 days
b. No disc hemorrhage 2159 days
XII. How these results affect how we manage glaucoma.
A. Grading Severity
1. Based on visual fields
2. Based on optic nerves
3. Based on pre-Tx IOP
B. Management when IOP is over 30 mmHg
1. Mild to moderate glaucoma
2. Advanced glaucoma
C. Management when IOP is 20-30 mmHg
1. Mild to moderate glaucoma
2. Advanced glaucoma
D. Management when IOP is less than 20 mmHg
1. Mild to moderate glaucoma
2. Advanced glaucoma
XIII. Lessons from the control groups in the studies: YOU HAVE TIME!!!
A. 90.5% of ocular hypertensives had no progression at 4 years
B. Untreated controls in the EMGT had a median survival time of 4 years
C. Untreated controls in the NTGS had a median survival time of 4.6 years
XIV. Reading References
1. Kass et al. The Ocular Hypertension Treatment Trial. A randomized trial determines
that topical ocular hypotensive medication delays or prevents the onset of POAG. Arch
Ophthalmol 2002;120:701-713.
2. Gordon et al. The Ocular Hypertension Treatment Trial. Baseline factors that predict
the onset of POAG. Arch Ophthalmol 2002;120:714-720.
3. Heijl et al. The Early Manifest Glaucoma Trial. Reduction of IOP and Glaucoma
Progression. Arch Ophthalmol 2002;120:1268-1279.
4. Leske et al. The Early Manifest Glaucoma Trial. Factors for Glaucoma Progression and
the Effect of Treatment. Arch Ophthalmol 2003;121:48-56.
5. Lichter et al. Interim Clinical Outcomes in the Collaborative Initial Glaucoma Treatment
Study Comparing Initial Treatment Randomized to Medication or Surgery.
Ophthalmology 2001;108(11):1943-1953.
6. VanVeldhuisen et al. The Advanced Glaucoma Intervention Study: 7: The relationship
between control of IOP and visual field deterioration. Am J Ophthalmol
2000;130(4):429-440.
7. Anderson et al. Collaborative Normal Tension Glaucoma Study Group. Comparison of
glaucomatous progression between untreated patients with normal tension glaucoma
and patients with therapeutically reduced IOP. Am J Ophthalmol 1998;126(4):487497.
8. Drance et al. Collaborative Normal Tension Glaucoma Study Group. Risk factors for
progression of visual field abnormalities in NTG. Am J Ophthalmol 2001;131(6):699708.