4. “Doctor, why do we need to put those
expensive eye drops for glaucoma?”
Monday, March 11, 13
5. OHTS
• Ocular Hypertension Study
- Aim: To determine if glaucoma drops
delays or prevents glaucoma in ocular
hypertensives
Monday, March 11, 13
6. OHTS
• Ocular Hypertension Study
- 1,636 patients
- 10 years of follow-up
- Main Outcome Measures:
AVFs and stereoscopic optic disc photos
Arch Ophthalmol 120: 701-713, 2002
Monday, March 11, 13
7. OHTS
Ocular Hypertension Study
• Entry criteria: ages 40 to 80;
normal visual fields and normal optic discs;
untreated IOP of 24 to 32 mmHg in one eye,
21 to 32 mmHg in fellow eye
• Initially randomized to:
- observation
- stepped topical medical regimen
Monday, March 11, 13
8. OHTS
Ocular Hypertension Study
• KEY FINDINGS
- First to demonstrate that lowering IOP
delays/prevents glaucoma
- Identified risk factors in developing
POAG
Monday, March 11, 13
9. OHTS
Ocular Hypertension Study
• First to demonstrate that lowering IOP
delays/prevents glaucoma
- treated group: 4.4% developed POAG
- observation: 9.5%
Monday, March 11, 13
10. OHTS
Ocular Hypertension Study
• Identified risk factors in developing POAG
- IOP, age, central corneal thickness,
vertical cup to disc ratio, PSD
- established low-, mid- to high-risk groups
Monday, March 11, 13
11. OHTS
Ocular Hypertension Study
• Lessons for Clinicians
- Take risk categories into account
- Consider observation before treatment
in some patients
Monday, March 11, 13
12. OHTS
Ocular Hypertension Study
• Lessons for Clinicians
- Treat those with:
‣ older age
‣ high cup to disk ratio
‣ high PSD in AVFs
‣ thin corneas
Monday, March 11, 13
13. “Doctor, I just learned I have glaucoma,
which is better - drops or surgery?”
Monday, March 11, 13
14. CIGTS
Collaborative Initial Glaucoma Treatment Study
• Trabeculectomy vs drugs for initial therapy
- Effect on early diagnosed open-angle
glaucoma of treatment with topical meds
or trabeculectomy
Ophthalmology 106: 653-62, 1999
Monday, March 11, 13
15. CIGTS
• Collaborative Initial Glaucoma Treatment Study
- 607 patients
- 5-9 years of follow-up
- Main Outcome Measure: AVFs
Monday, March 11, 13
16. CIGTS
Collaborative Initial Glaucoma Treatment Study
• Entry criteria: IOP of 20 mmHg or greater;
optic nerve damage and / or
visual field loss in one or both eyes
• Randomized initial treatment:
- with stepped topical medication
- trabeculectomy
Monday, March 11, 13
17. CIGTS
Collaborative Initial Glaucoma Treatment Study
• KEY FINDINGS
- Aggressive IOP targets yield results
- Quality of Life measured
Monday, March 11, 13
18. CIGTS
Collaborative Initial Glaucoma Treatment Study
• Aggressive IOP targets yield results
- 35% reduction from medication
- 48% reduction from surgery
Monday, March 11, 13
19. CIGTS
Collaborative Initial Glaucoma Treatment Study
• Lessons for Clinicians
- Consider surgery first in patients with
moderate or advanced disease
- Keep IOP steady
- Major surgical complications are few
Monday, March 11, 13
20. CIGTS
Collaborative Initial Glaucoma Treatment Study
• Lessons for Clinicians
- Surgery resulted in:
‣ lower IOP
‣ more cataracts
‣ more ocular side effects
‣ initial decreased vision
‣ initial decreased visual field
Monday, March 11, 13
21. “Doctor, I stopped my glaucoma medications,
what will happen to my eyes?”
Monday, March 11, 13
23. EMGT
• Early Manifest Glaucoma Trial
- 255 patients
- 7 to 11 years of follow-up
- Main Outcome Measures:
AVFs and optic disc photos
Monday, March 11, 13
24. EMGT
Early Manifest Glaucoma Trial
• Entry criteria: median visual field mean deviation
of –4 dB and median IOP of 20 mmHg
• Randomized to:
- initial treatment with a selective beta-blocker
and ALT
- left untreated until signs of progression
appeared
Monday, March 11, 13
25. EMGT
Early Manifest Glaucoma Trial
• KEY FINDINGS
- Treatment effect validated
- Every 1 mmHg reduction matters
- Disease progression is variable
- Mean IOP is vital
Monday, March 11, 13
26. EMGT
Early Manifest Glaucoma Trial
• Lessons for clinicians
- Follow progression closely; reset target
as needed
- Exfoliation as a risk factor
- Strive for the lower IOP
Monday, March 11, 13
27. EMGT
Early Manifest Glaucoma Trial
• Lessons for clinicians
- Aggressive treatment if:
‣ pseudoexfoliation
‣ bilateral disease
‣ older patient
‣ higher IOP
‣ worse mean deviation
‣ disc hemorrhage
Monday, March 11, 13
28. “Doctor, why do I have glaucoma if my pressure is
20 mmHg?”
Monday, March 11, 13
29. CNTGS
Collaborative Normal-Tension Glaucoma Study
• IOP reduction important even for
normotensives
Curr Opin Ophthalmol. 2003;14(2):86-90.
Monday, March 11, 13
30. CNTGS
• Collaborative Normal-Tension Glaucoma Study
- 260 patients
- > 5 years of follow up
- Main Outcome Measures: AVF
Monday, March 11, 13
31. CNTGS
Collaborative Normal-Tension Glaucoma Study
• Entry criteria: eyes with either progressive NTG or
NTG with field defects impinging on the point of
fixation
• Randomized to receive:
• no therapy
• IOP lowering by 30 percent with medication
(pilocarpine or carbonic anhydrase inhibitor),
laser, filtering surgery or a combination
Monday, March 11, 13
32. CNTGS
Collaborative Normal-Tension Glaucoma Study
• KEY FINDINGS
- IOP plays a role in NTG
- Cataract confounders
- Over half of patients did not progress
without treatment at 5 years
Monday, March 11, 13
33. CNTGS
Collaborative Normal-Tension Glaucoma Study
• Lessons for Clinicians
- Distinguish between progressive and non-
progressive disease
- Surgery may not be necessary
Monday, March 11, 13
34. CNTGS
Collaborative Normal-Tension Glaucoma Study
• Lessons for Clinicians
- Aggressive treatment if:
- female patient
- presence of migraine
- disc hemorrhages
Monday, March 11, 13
35. “Doctor, which treatment is better for my glaucoma -
trabeculectomy or laser?”
Monday, March 11, 13
36. AGIS
Advanced Glaucoma Interventional Study
• Aim: To assess the outcome of sequences
of laser and surgical interventions in eyes that
have failed on medical treatment
Controlled Clinical Trials 15(4): 299-325, 1994.
Monday, March 11, 13
37. AGIS
• Advanced Glaucoma Interventional Study
- 591 patients
- 8-11 years of follow up
- Main Outcome Measures: sustained
decrease of visual field and visual acuity
Monday, March 11, 13
38. AGIS
Advanced Glaucoma Interventional Study
• Entry criteria: patient on maximum tolerated
medical therapy, baseline VA score 56 or better
in the study eye, baseline AGIS visual field score
of 1 to 16
• Randomized to receive:
• ALT > trabeculectomy > trabeculectomy (ATT)
• trabeculectomy > ALT > trabeculectomy (TAT)
Monday, March 11, 13
39. AGIS
Advanced Glaucoma Interventional Study
• KEY FINDINGS
- Reducing IOP slows visual field loss
- Many patients achieved stability
- Race affected outcomes
Monday, March 11, 13
40. AGIS
Advanced Glaucoma Interventional Study
• Lessons for clinicians
- Take race into account when choosing
therapy
- Blacks should have laser first
- Whites should have trabeculectomy
first
Monday, March 11, 13
41. “Doctor, which surgery is better for my glaucoma -
trabeculectomy or tube?”
Monday, March 11, 13
42. TVT
• Trabeculectomy vs Tube Study
- 212 patients
- 5 years of follow-up
- Main Outcome Measures:
IOP, VA, AVF, surgical complications,
treatment failures
Am J Ophthalmol. 2009;148(5):670-684.
Monday, March 11, 13
43. TVT
Trabeculectomy vs Tube Study
• Entry criteria: prior cataract or glaucoma
filtering surgery and uncontrolled glaucoma
with IOP of 18 mmHg to 40 mmHg on
maximum tolerated medical therapy
• Randomized to receive:
• either tube shunt surgery and/or
• trabeculectomy with mitomycin C (MMC)
Monday, March 11, 13
44. TVT
Trabeculectomy vs Tube Study
• KEY FINDINGS
- Trab vs. shunt: no clear winner
- Complications and failure rates
Monday, March 11, 13
45. TVT
Trabeculectomy vs Tube Study
• Lessons for Clinicians
- Put tubes in armamentarium
- Assess patient’s unique needs
Monday, March 11, 13
46. Recap
• Present glaucoma clinical practice
guidelines have strong evidences
• Identification of risk factors, degree of
disease and quality of life is key
• Customize treatment
Monday, March 11, 13
47. Thank you for your
attention :)
Monday, March 11, 13
