Background Primary open-angle glaucoma (POAG) is one of the leading causes of blindness in the United States and worldwide. Three to 6 million people in the United States are at increased risk for developing POAG because of elevated intraocular pressure (IOP), or ocular hypertension. There is no consensus on the efficacy of medical treatment in delaying or preventing the onset of POAG in individuals with elevated IOP. Therefore, we designed a randomized clinical trial, the Ocular Hypertension Treatment Study. Objective To determine the safety and efficacy of topical ocular hypotensive medication in delaying or preventing the onset of POAG. Methods A total of 1636 participants with no evidence of glaucomatous damage, aged 40 to 80 years, and with an IOP between 24 mm Hg and 32 mm Hg in one eye and between 21 mm Hg and 32 mm Hg in the other eye were randomized to either observation or treatment with commercially available topical ocular hypotensive medication. The goal in the medication group was to reduce the IOP by 20% or more and to reach an IOP of 24 mm Hg or less. Main Outcome Measures The primary outcome was the development of reproducible visual field abnormality or reproducible optic disc deterioration attributed to POAG. Abnormalities were determined by masked certified readers at the reading centers, and attribution to POAG was decided by the masked Endpoint Committee. Results During the course of the study, the mean ± SD reduction in IOP in the medication group was 22.5% ± 9.9%. The IOP declined by 4.0%± 11.6% in the observation group. At 60 months, the cumulative probability of developing POAG was 4.4% in the medication group and 9.5% in the observation group (hazard ratio, 0.40; 95% confidence interval, 0.27-0.59; P Conclusions Topical ocular hypotensive medication was effective in delaying or preventing the onset of POAG in individuals with elevated IOP. Although this does not imply that all patients with borderline or elevated IOP should receive medication, clinicians should consider initiating treatment for individuals with ocular hypertension who are at moderate or high risk for developing POAG.

https://jamanetwork.com/journals/jamaophthalmology/articlepdf/270953/ecs20045.pdf

The Ocular Hypertension Treatment Study: A Randomized Trial Determines That Topical Ocular Hypotensive Medication Delays or Prevents the Onset of Primary Open-Angle Glaucoma

Objective To provide the results of the Early Manifest Glaucoma Trial, which compared the effect of immediately lowering the intraocular pressure (IOP), vs no treatment or later treatment, on the progression of newly detected open-angle glaucoma. Design Randomized clinical trial. Participants Two hundred fifty-five patients aged 50 to 80 years (median, 68 years) with early glaucoma, visual field defects (median mean deviation, −4 dB), and a median IOP of 20 mm Hg, mainly identified through a population screening. Patients with an IOP greater than 30 mm Hg or advanced visual field loss were ineligible. Interventions Patients were randomized to either laser trabeculoplasty plus topical betaxolol hydrochloride (n = 129) or no initial treatment (n = 126). Study visits included Humphrey Full Threshold 30-2 visual field tests and tonometry every 3 months, and optic disc photography every 6 months. Decisions regarding treatment were made jointly with the patient when progression occurred and thereafter. Main Outcome Measures Glaucoma progression was defined by specific visual field and optic disc outcomes. Criteria for perimetric progression were computer based and defined as the same 3 or more test point locations showing significant deterioration from baseline in glaucoma change probability maps from 3 consecutive tests. Optic disc progression was determined by masked graders using flicker chronoscopy plus side-by-side photogradings. Results After a median follow-up period of 6 years (range, 51-102 months), retention was excellent, with only 6 patients lost to follow-up for reasons other than death. On average, treatment reduced the IOP by 5.1 mm Hg or 25%, a reduction maintained throughout follow-up. Progression was less frequent in the treatment group (58/129; 45%) than in controls (78/126; 62%) ( P =.007) and occurred significantly later in treated patients. Treatment effects were also evident when stratifying patients by median IOP, mean deviation, and age as well as exfoliation status. Although patients reported few systemic or ocular conditions, increases in clinical nuclear lens opacity gradings were associated with treatment ( P = .002). Conclusions The Early Manifest Glaucoma Trial is the first adequately powered randomized trial with an untreated control arm to evaluate the effects of IOP reduction in patients with open-angle glaucoma who have elevated and normal IOP. Its intent-to-treat analysis showed considerable beneficial effects of treatment that significantly delayed progression. Whereas progression varied across patient categories, treatment effects were present in both older and younger patients, high- and normal-tension glaucoma, and eyes with less and greater visual field loss.

http://bmec.swbh.nhs.uk/wp-content/uploads/2013/03/Early-Manifest-Glaucoma-Trial.pdf

Reduction of intraocular pressure and glaucoma progression: results from the Early Manifest Glaucoma Trial.

Early manifest glaucoma trial group. reduction of intraocular pressure and glaucoma progression: results from the early manifest glaucoma trial

Importance Glaucoma is a worldwide leading cause of irreversible vision loss. Because it may be asymptomatic until a relatively late stage, diagnosis is frequently delayed. A general understanding of the disease pathophysiology, diagnosis, and treatment may assist primary care physicians in referring high-risk patients for comprehensive ophthalmologic examination and in more actively participating in the care of patients affected by this condition. Objective To describe current evidence regarding the pathophysiology and treatment of open-angle glaucoma and angle-closure glaucoma. Evidence Review A literature search was conducted using MEDLINE, the Cochrane Library, and manuscript references for studies published in English between January 2000 and September 2013 on the topics open-angle glaucoma and angle-closure glaucoma. From the 4334 abstracts screened, 210 articles were selected that contained information on pathophysiology and treatment with relevance to primary care physicians. Findings The glaucomas are a group of progressive optic neuropathies characterized by degeneration of retinal ganglion cells and resulting changes in the optic nerve head. Loss of ganglion cells is related to the level of intraocular pressure, but other factors may also play a role. Reduction of intraocular pressure is the only proven method to treat the disease. Although treatment is usually initiated with ocular hypotensive drops, laser trabeculoplasty and surgery may also be used to slow disease progression. Conclusions and Relevance Primary care physicians can play an important role in the diagnosis of glaucoma by referring patients with positive family history or with suspicious optic nerve head findings for complete ophthalmologic examination. They can improve treatment outcomes by reinforcing the importance of medication adherence and persistence and by recognizing adverse reactions from glaucoma medications and surgeries.

https://jamanetwork.com/journals/jama/articlepdf/1869215/jrv140004.pdf

The Pathophysiology and Treatment of Glaucoma: A Review

Primary open-angle glaucoma.

The advanced glaucoma intervention study (AGIS): 7. the relationship between control of intraocular pressure and visual field deterioration

The Advanced Glaucoma Intervention Study (AGIS): 13. Comparison of treatment outcomes within race: 10-year results.

Purpose: To compare the visual outcome and refractive status of children with primary congenital glaucoma who underwent 360° trabeculotomy or goniotomy as an initial surgical procedure. Methods: This retrospective study describes 24 eyes (15 patients) with primary congenital glaucoma that underwent 360° trabeculotomy as the initial procedure and 40 eyes (23 patients) that underwent goniotomy as the initial procedure. Inclusion criteria were: (1) diagnosis of primary congenital glaucoma and initial angle surgery before 1 year of age, (2) no other ocular or systemic diseases, (3) 360° trabeculotomy or goniotomy as the first surgical procedure, and (4) ability to obtain an Allen or Snellen visual acuity. A postoperative vision of 20/50 or better was considered good. Surgical success was defined as an intraocular pressure (IOP) less than 22 mm Hg with or without medication and without evidence of a progressive optic neuropathy. Results: The IOP was successfully controlled in 92% of eyes in the trabeculotomy group and in 58% of eyes in the goniotomy group ( P =.004). Of eyes in the trabeculotomy group, 79% had vision of 20/50 or better compared with 53% in the goniotomy group ( P =.03). High myopia was more prevalent in the goniotomy group, but this difference was not statistically significant ( P =.16). A poor visual outcome was associated with failure of the angle surgery or poor compliance with follow-up and amblyopia therapy. Conclusion: For primary congenital glaucoma, 360° trabeculotomy is a highly effective procedure that results in excellent pressure control and is at least as successful as multiple standard procedures. In this study, 360° trabeculotomy resulted in better vision than what is reported in the literature for standard angle procedures. (J AAPOS 2000;4:205–10)

Long-term surgical and visual outcomes in primary congenital glaucoma: 360° trabeculotomy versus goniotomy

Aqueous shunt devices compared with trabeculectomy with Mitomycin-C for children in the first two years of life.

We have refined a technique for performing 360 degrees trabeculotomy in a single procedure using a 6-0 polypropylene (Prolene) suture fragment and have used it in 15 patients (26 eyes) with primary congenital glaucoma. The refined technique can be performed via a single nasal surgical site. This procedure avoids many of the difficulties encountered with metal trabeculotomes and preserves conjunctiva should further glaucoma surgery be necessary.

Allen D. Beck

Papers

The advanced glaucoma intervention study (AGIS): 7. the relationship between control of intraocular pressure and visual field deterioration

The Advanced Glaucoma Intervention Study (AGIS): 13. Comparison of treatment outcomes within race: 10-year results.

Long-term surgical and visual outcomes in primary congenital glaucoma: 360° trabeculotomy versus goniotomy

Aqueous shunt devices compared with trabeculectomy with Mitomycin-C for children in the first two years of life.

360° Trabeculotomy for Primary Congenital Glaucoma