WOC symposium: Individualized therapy provides best glaucoma management

June 29, 2008

Glaucoma progresses at different rates among patients, and this variability poses a challenge for the ophthalmologist trying to manage the disease. IOP is a well-known risk factor and often is monitored carefully in patients with glaucoma. However, visual field and optic nerve deterioration are direct indicators of progression, and their status also should be considered when developing an initial treatment plan.

Glaucoma progresses at different rates among patients, and this variability poses a challenge for the ophthalmologist tryingto manage the disease. IOP is a well-known risk factor and often is monitored carefully in patients with glaucoma. However,visual field and optic nerve deterioration are direct indicators of progression, and their status also should be consideredwhen developing an initial treatment plan.

That was among the information presented at "Pre-empting progression in clinical practice: detection, prediction, andclinical management of progression," a symposium held here in conjunction with the World Ophthalmology Congress (WOC).Risk factors cannot predict those patients who will progress, or time to progression, said Anders Heijl, MD, president,Glaucoma Research Society, and professor and chairman, Lund University, Malmö University Hospital, Sweden. "Progressionin manifest glaucoma is variable, and the risk factors only explain part of that variability."

He advised that patients be followed closely, preferably with standard automated perimetry.

Dr. Heijl, study director of the Early Manifest Glaucoma Trial, recommended following patients in whom glaucoma is newlydiagnosed the most closely. He also advised using the same threshold test.

"Any analysis of progression can only be undertaken if the same threshold algorithm and test pattern is used," he said.David Garway-Heath, MD, FRCOphth, clinical research lead of the Glaucoma Unit and consultant ophthalmologist, Moorsfield EyeHospital, United Kingdom, said that the actual progression rate is unknown in the early course of glaucoma management.Therefore, known risk factors and markers for progression must be used to determine patients who are at risk for rapidprogression.

"Risk factors may tell us that one-third of patients may progress, but they don't tell us which one-third," Dr. Garway-Heathsaid. Nevertheless, risk profiling is still a valuable tool, he said.

Risk factors that have been consistent across major studies include high IOP at both baseline and follow-up, greater age,pseudoexfoliation syndrome, and percentage of patients who have disc hemorrhages at follow-up, he said. There is growingevidence that central corneal thickness soon will join that list, he added.

Robert N. Weinreb, MD, distinguished professor of ophthalmology and director, Hamilton Glaucoma Center, University ofCalifornia, La Jolla, CA, said that in order to optimize the potential for successful treatment of glaucoma, it's necessary toassess progression and individualize treatment accordingly.

Four important steps exist in creating a successful treatment plan to manage glaucoma progression in clinical practice, Dr.Weinreb said. Those steps are establishing a baseline, including an assessment of optic nerve structure, visual function, andIOP; estimating the patient's life expectancy; developing a risk profile; and making individualized treatment decisions."Then conduct lifelong disease surveillance," he said.

As for treatment, L. Jay Katz, MD, FACS, professor, Jefferson Medical College and attending surgeon and co-director,glaucoma, Wills Eye, Philadelphia, said that protaglandins are replacing beta-blockers as the gold standard inmonotherapy.

"The efficacy of protaglandins is outstanding, and once-a-day dosing increases patient compliance," he said.Progression of glaucoma, as documented by perimetry or optic nerve changes, triggers more aggressive IOP reduction, he added.By using a proactive approach, clinicians may be able to customize IOP targets and IOP-lowering therapy based on anindividual patient's risk of progression.