Canadian Ophthalmological Society

1
Canadian Ophthalmological Society

• Evidence-based Clinical Practice Guidelines for
  the Management of Glaucoma in the Adult Eye

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Glaucoma Therapies
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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
  interventionas 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
200944(Suppl 1)S1?S93.
4
Quality-of-life considerations

• Glaucomatous field damage adversely affects the
  patients 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
2003314826. 2. Altangerel U, et al. Curr Opin
Ophthalmol 2003141005. 3. Janz NK, et al.
Ophthalmology 200110888797. 4 .Haymes SA, et
al. Invest Ophthalmol Vis Sci 200748114955.
Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
5
Overall and specific managementgoals in patients
with glaucoma
Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
6
Lowering IOP andSetting Target IOP
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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
200013042940. 2. Collaborative Normal-Tension
Glaucoma Study Group.Am J Ophthalmol
199812648797. 3. Heijl A, et al. Arch
Ophthalmol 2002120126879. 4. Chauhan BC, et
al. Arch Ophthalmol 200812610306.
Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
8
Lowering IOP (contd)

• 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

• AGIS Investigators. Am J Ophthalmol
  200013042940.
• Asrani S, et al. J Glaucoma 2000913442.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
9
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

• American Academy of Ophthalmology. Primary
  Open-Angle Glaucoma. Preferred Practice Pattern.
  San Francisco, CA American Academy of
  Ophthalmology 2005.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
10
Setting target IOP (contd)

• 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
• patients 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
200944(Suppl 1)S1?S93.
11
Staging each eye forglaucoma damage
Adapted from Damji KF, et al. Can J Ophthalmol
20033818997. Refers to vertical C/D ratio in
an average size nerve. If the nerve is small,
then a smaller C/D ratiomay still be
significant conversely, a large nerve may have a
large vertical C/D ratio and still bewithin
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
200944(Suppl 1)S1?S93.
12
Suggested upper limit of initialtarget IOP for
each eye
Adapted from Damji KF, et al. Can J Ophthalmol
20033818997. 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
200944(Suppl 1)S1?S93.
13
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
200944(Suppl 1)S1?S93.
14
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
200944(Suppl 1)S1?S93.