Canadian Ophthalmological Society

1
Canadian Ophthalmological Society

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

2
Progression
3
Definition of progression

• A patients glaucoma is deemed to have progressed
  if structural and (or) functional changes,
  associated with the disease, are verifiably
  detected on clinical examination and (or)
  testing.
• The clinical significance of this progression,
  and the actions taken, will be influenced by
• the extent of damage prior to the change, and
• the threat of visual handicap if further
  progression were to occur.

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
Methods of detecting progression

• Progression may be detected, clinically or with
  the aid of various technological investigations,
  as loss of tissue (structural) and/or vision
  (function).
• Careful ophthalmoscopy and precise documentation
  (i.e., photography or imaging) may confirm loss
  of RNFL or optic disc tissue over time.

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
Methods of detectingprogression (contd)

• Confirming progressive vision loss requires
  threshold evaluation of the peripheral field.
• In both instances, the potential for greater
  sensitivity and quantification of change
  mayexist for technologically based evaluations
  compared with clinical examinations alone.

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
Endpoints for conversion to, or progression of,
glaucoma in major RCTs
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.
7
Progression technology choices

• Recommendation
• Assessing disease severity is important to
  determine which tests might be most useful for
  each individual. Patients with glaucoma should be
  monitored with both structural and functional
  tests, as progression can be detected by either
  method alone Level 21.

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.
1. Artes PH, et al. Prog Retin Eye
Res20052433354.
8
VF progression endpoints forthe major glaucoma
RCTs
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
Advantages and disadvantages ofevent-based and
trend-basedapproaches to VF progression
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
Progression correlationbetween structure and
function

• Recommendation
• It is recommended that a correlation between
  structural and functional changes be sought in
  suspected progression, even though it is more
  common for a change to be detected with one or
  the other independently Level 11-4.

1. Collaborative Normal-Tension Glaucoma Study
Group.Am J Ophthalmol 199812648797. 2. Kass
MA, et al. Arch Ophthalmol 200212070113. 3.
Heijl A, et al. Arch Ophthalmol
2002120126879. 4. Miglior S, et al
Ophthalmology 2002109161221.
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
Risk factors and their relationshipto VF
progression examinedin the landmark RCTs
Positively associated if more severe baseline VF
damage resulted in greater degree of VF
progression Positive association in patients
with low mean IOPs and not high mean IOPs
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
Risk factors and their relationshipto VF
progression examinedin the landmark RCTs
Positive association in ATT and not TAT sequence
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
Progression significant forthe patient

• The significance of a detectable structural and
  (or) functional change would be different for
  different patients.
• The ophthalmologists response should reflect the
  significance to the patient.

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
Progression significant forthe patient (contd)

• Significance and action taken would be influenced
  by some of the following considerations
• What is the baseline level of glaucomatous damage
  (i.e., is the VF full with a nearly
  normal-appearing disc, or is fixation threatened
  in 3 of 4 quadrants)?
• What is the status of the fellow eye?
• What is the health of the patient and life
  expectancy?
• What are the visual demands of the patient (e.g.,
  is he or shestill driving)?
• What is the next step? Is it heightened
  surveillance or is it incisional surgery?
• What is the patients interpretation of the
  change and the proposed actions?

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.
15
Visual field progression confirmation

• Recommendation
• The clinicians response to a new progressive
  event should be to confirm the change with a
  repeat test. VFs may need to be performed more
  frequently during periods of apparent
  progression. Ultimately, it is most important to
  calculate the rate of progression over time
  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.
16
Number of annual VF tests neededto detect total
mean deviationchange over 2, 3, and 5 years
Adapted from Chauhan BC, et al. Br J Ophthalmol
20089256973.
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.
17
Visual field baseline

• Recommendation
• In order to establish a good baseline and to
  detect possible rapid progression, several VFs
  should be performed at regular intervals in the
  first 2 years 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.
18
Frequency of follow-up

• Frequency of follow-up is influenced by a number
  of factors.
• Patients with stable glaucoma, or ocular
  hypertension who are on treatment, need
  assessment at least once a year.
• Depending on disease severity, other patients
  will require more frequent assessments.
• Clinical judgment and common sense should be
  exercised when dealing with very elderly patients
  who travel long distances for follow-up,
  particularly duringthe winter.

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.
19
Recommended clinical assessmentintervals for
stable chronic glaucomas
Assessments might include any of the components
listed in Table 2 in addition to documentation of
the optic disc and VF testing. More frequent
evaluations may be necessary if indications
listed in Table 17 are noted. It may be
necessary to see patients with advanced glaucoma
very frequently (weeks or days) if their IOP is
poorly controlled, progression appears rapid or
fixation is threatened.
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.
20
Indications for more frequent follow-upor
heightened surveillance
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.
21
Progression Treatment goals

• Some degree of progression may be unavoidable in
  glaucoma.
• Goals for the clinician include
• measuring and minimizing the progression,
• preserving or enhancing QOL, and
• choosing a management scheme that is appropriate
  and acceptable to the patient.

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.