Trials provide practical perspectives on glaucoma

San Francisco-Results from randomized, controlled clinical trials provide clear evidence that for most patients, glaucoma is an IOP-sensitive optic neuropathy for which lowering IOP is effective in slowing or arresting progression, said Gregory L. Skuta, MD, in his presentation of the Shaffer-Hetherington-Hoskins Lecture at the 16th annual Glaucoma Symposium during Glaucoma 360.

Reviewing results from the Collaborative Normal-Tension Glaucoma Study, Collaborative Initial Glaucoma Treatment Study, Advanced Glaucoma Intervention Study, and Tube Versus Trabeculectomy Study, Dr. Skuta concluded that in patients with glaucoma, ophthalmologists should aim to lower IOP by 30% to 35% and perhaps even more aggressively in patients with more advanced glaucoma. Dr. Skuta is president and chief executive officer, Dean McGee Eye Institute, and the Edward L. Gaylord Professor and Chair, Department of Ophthalmology, University of Oklahoma, Oklahoma City.

He noted that data from the Ocular Hypertension Treatment Study (OHTS) and the OHTS 2 also showed a significant benefit of IOP-lowering for preventing onset of glaucoma, even if medical treatment initiation is delayed. Additional analyses of OHTS data taught other lessons that are useful in daily practice, including that progression can occur as a change in the optic disc without a detectable change in the visual field. Data from the OHTS and European Glaucoma Prevention Study also identified risk factors for progression to glaucoma, leading to the development of risk calculators that are useful for guiding treatment decisions for patients with ocular hypertension (OHT).

“OHTS taught us that it pays to treat at least some patients with OHT, and the risk calculators give us a better grasp of who to treat,” Dr. Skuta said.

Nevertheless, there are some patients whose glaucoma continues to get worse despite seemingly good IOP control. Issues to consider for these patients include medication noncompliance, angle status, IOP fluctuation, ocular perfusion pressure, and sleep disorders.

“We know that noncompliance is a common problem in our glaucoma population, and there is some evidence that better control of diurnal and long-term IOP variation would likely result in further visual preservation,” he said.

“Don’t forget to look at the angle periodically, and think about blood pressure and its effect on perfusion pressure,” Dr. Skuta said. “When indicated, I will communicate with the primary-care doctor about the patient’s blood pressure to make sure we are working together in helping the patient maintain vision and general health.”

The 2012 symposium was sponsored by the Glaucoma Research and Education Group and concluded the Glaucoma 360 meeting, a 3-day event presented by the Glaucoma Research Foundation in association with Ophthalmology Times.