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Primary Open Angle Glaucoma

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Last updated: February 8th, 2022

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Summary of Evidence

Low intraocular pressure is associated with decreased progression of visual field defect.(AGIS, 2000) {The Advanced Glaucoma Intervention Study (AGIS): 7. The relationship between control of intraocular pressure and visual field deterioration.The AGIS Investigators. Am J Ophthalmol. 2000 Oct;130(4):429-40.}

 

Both initial medical or initial surgical therapy resulted in similar visual field outcome at 5 years.(CIGTS, 2001) {Lichter PR, Musch DC, Gillespie BW, Guire KE, Janz NK, Wren PA, Mills RP; CIGTS Study Group. Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery. Ophthalmology. 2001 Nov;108(11):1943-53.}

 

Treatment to lower intraocular pressure significantly delays progression in early OAG.(EMGTS, 2002) {Leske MC, Heijl A, Hyman L, Bengtsson B, Dong L, Yang Z; EMGT Group. Predictors of long-term progression in the early manifest glaucoma trial. Ophthalmology. 2007 Nov;114(11):1965-72.}

 

Medical treatment in open-angle glaucoma results in preservation of the visual field.(UKGTS, 2015) {Garway-Heath DF, Crabb DP, Bunce C, Lascaratos G, Amalfitano F, Anand N, Azuara-Blanco A, Bourne RR, Broadway DC, Cunliffe IA, Diamond JP, Fraser SG, Ho TA, Martin KR, McNaught AI, Negi A, Patel K, Russell RA, Shah A, Spry PG, Suzuki K, White ET, Wormald RP, Xing W, Zeyen TG. Latanoprost for open-angle glaucoma (UKGTS): a randomised, multicentre, placebo-controlled trial. Lancet. 2015 Apr 4;385(9975):1295-304.}

 

In newly diagnosed glaucoma patients, intensive treatment with multiple medications + SLT led to considerably greater IOP reduction than stepwise mono‐therapy at 1 month.(GITS, 2018) {Lindén C, Heijl A, Jóhannesson G, Aspberg J, Andersson Geimer S, Bengtsson B. Initial intraocular pressure reduction by mono- versus multi-therapy in patients with open-angle glaucoma: results from the Glaucoma Intensive Treatment Study. Acta Ophthalmol. 2018 Sep;96(6):567-572.}

Evidence

1. Background

1.1 Epidemiology

Systematic Review

2021 Soh et.al.

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2021
Systematic Review

Undetected glaucoma is highly prevalent across diverse communities worldwide and more common in Africa and Asia; In 2020, 43.78 million POAG cases were projected to be undetected, of which 76.7% were in Africa and Asia. {Soh Z, Yu M, Betzler BK, Majithia S, Thakur S, Tham YC, Wong TY, Aung T, Friedman DS, Cheng CY. The Global Extent of Undetected Glaucoma in Adults: A Systematic Review and Meta-analysis. Ophthalmology. 2021 Oct;128(10):1393-1404.}

  • Randomized controlled trial of latanoprost vs placebo in newly diagnosed open angle glaucoma (516 patients).
  • Findings:
    • Mean reduction in intraocular pressure was 3·8 mm Hg in the latanoprost group and 0·9 mm Hg in the placebo group.
    • Visual field preservation was significantly longer in the latanoprost group than in the placebo group

Soh et.al.
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1.2 General management principles

Clinical Trial

2015 Garway-Heath et.al. (UKGTS)

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2015
Clinical Trial

Medical treatment in open-angle glaucoma results in preservation of the visual field. {Garway-Heath DF, Crabb DP, Bunce C, Lascaratos G, Amalfitano F, Anand N, Azuara-Blanco A, Bourne RR, Broadway DC, Cunliffe IA, Diamond JP, Fraser SG, Ho TA, Martin KR, McNaught AI, Negi A, Patel K, Russell RA, Shah A, Spry PG, Suzuki K, White ET, Wormald RP, Xing W, Zeyen TG. Latanoprost for open-angle glaucoma (UKGTS): a randomised, multicentre, placebo-controlled trial. Lancet. 2015 Apr 4;385(9975):1295-304.}

  • Randomized controlled trial of latanoprost vs placebo in newly diagnosed open angle glaucoma (516 patients).
  • Findings:
    • Mean reduction in intraocular pressure was 3·8 mm Hg in the latanoprost group and 0·9 mm Hg in the placebo group.
    • Visual field preservation was significantly longer in the latanoprost group than in the placebo group

Garway-Heath et.al. (UKGTS)
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cited by count
Clinical Trial

2002 Leske et.al. (EMGTS)

Article link | Archive link | Metrics cited by count

2002
Clinical Trial

Treatment to lower intraocular pressure significantly delays progression in early OAG {Leske MC, Heijl A, Hyman L, Bengtsson B, Dong L, Yang Z; EMGT Group. Predictors of long-term progression in the early manifest glaucoma trial. Ophthalmology. 2007 Nov;114(11):1965-72.}

  • Randomized controlled trial of treatment vs observation in Ocular Hypertension and early Open Angle Glaucoma (n=255)
  • Findings:
    • IOP was lowered by an average of 5.1mmHg or 25% throughout followup
    • Glaucoma progression was less frequent in the treatment group (45%) than in controls (62%) and occurred significantly later in treated patients

Leske et.al. (EMGTS)
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cited by count
Clinical Trial

2000 AGIS investigators (AGIS)

Article link | Archive link | Metrics cited by count

2000
Clinical Trial

Low intraocular pressure is associated with decreased progression of visual field defect {The Advanced Glaucoma Intervention Study (AGIS): 7. The relationship between control of intraocular pressure and visual field deterioration.The AGIS Investigators. Am J Ophthalmol. 2000 Oct;130(4):429-40.}

  • Randomized controlled trial of two sequences of glaucoma surgery in  medically uncontrolled glaucoma (738 eyes)
  • Findings:
    • Patients with IOP > 17.5 had worse visual field defect score than those with IOP < 14. Patients with IOP < 18 over 6 years had minimal change in VF defect score

AGIS investigators (AGIS)
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2. Medical treatment


Main article: Medical treatment of Glaucoma


2.1 Treatment approach

Clinical Trial

2018 Lindén et.al. (GITS)

Article link | Archive link | Metrics cited by count

2018
Clinical Trial

In newly diagnosed glaucoma patients, intensive treatment with multiple medications + SLT led to considerably greater IOP reduction than stepwise mono‐therapy at 1 month. {Lindén C, Heijl A, Jóhannesson G, Aspberg J, Andersson Geimer S, Bengtsson B. Initial intraocular pressure reduction by mono- versus multi-therapy in patients with open-angle glaucoma: results from the Glaucoma Intensive Treatment Study. Acta Ophthalmol. 2018 Sep;96(6):567-572.}

  • Randomized controlled trial of immediate intensive treatment vs conventional stepwise treatment in subjects with newly diagnosed glaucoma (295 eyes of 240 patinets).
  • Findings:
    • The median IOP reduction was 11.0 in the intensive group and 6.3 in the conventional group at 1 month.
    • A larger proportion of the multi‐therapy patients reached each target IOP level

Lindén et.al. (GITS)
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cited by count
Clinical Trial

2001 Lichter et.al. (CIGTS)

Article link | Archive link | Metrics cited by count

2001
Clinical Trial

Both initial medical or initial surgical therapy resulted in similar visual field outcome at 5 years {Lichter PR, Musch DC, Gillespie BW, Guire KE, Janz NK, Wren PA, Mills RP; CIGTS Study Group. Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery. Ophthalmology. 2001 Nov;108(11):1943-53.}

  • Randomized controlled trial of initial medical vs initial surgical treatment in newly diagnosed open angle glaucoma (607 patients).
  • Findings:
    • There was no significant difference in visual field loss between both groups.
    • Patients who underwent initial surgery had greater risk of substantial visual acuity loss compared to initial medical treatment, although average VA was similar by 4 years.
    • The rate of cataract removal was greater in the initial surgical group.

Lichter et.al. (CIGTS)
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cited by count

3. Laser treatment


Main article: Laser treatment of Glaucoma


4. Microinvasive Glaucoma Surgery


Main article: Microinvasive Glaucoma Surgery


5. Surgical treatment

Main article: Surgical treatment of glaucoma

Clinical Trial

2001 Lichter et.al. (CIGTS)

Article link | Archive link | Metrics cited by count

2001
Clinical Trial

Both initial medical or initial surgical therapy resulted in similar visual field outcome at 5 years {Lichter PR, Musch DC, Gillespie BW, Guire KE, Janz NK, Wren PA, Mills RP; CIGTS Study Group. Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery. Ophthalmology. 2001 Nov;108(11):1943-53.}

  • Randomized controlled trial of initial medical vs initial surgical treatment in newly diagnosed open angle glaucoma (607 patients).
  • Findings:
    • There was no significant difference in visual field loss between both groups.
    • Patients who underwent initial surgery had greater risk of substantial visual acuity loss compared to initial medical treatment, although average VA was similar by 4 years.
    • The rate of cataract removal was greater in the initial surgical group.

Lichter et.al. (CIGTS)
Journal full text Archive Metrics

cited by count

References

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