This publication is provided for historical reference only and the information may be out of date.
Research Focus for Clinicians
In response to a request from the public regarding treatments for open-angle glaucoma (OAG), a systematic review was undertaken to summarize the evidence regarding the comparative effectiveness and safety of medications and laser and other surgical treatments for OAG in adults. This review only included studies with clearly defined OAG participants ≥40 years of age and did not cover juvenile/congenital, traumatic, neovascular, refractory, or inflammatory glaucoma. The review included 109 clinical studies (73 randomized controlled trials, 13 observational studies, and 23 systematic reviews) that were published through October 2011. This summary is provided to assist in decisionmaking along with a patient's values and preferences. Reviews of evidence should not be construed to represent clinical recommendations or guidelines. The full report is available at www.effectivehealthcare.ahrq.gov/glaucomatreatment.cfm.
Background
Glaucoma is a leading cause of irreversible visual impairment and blindness worldwide and is a result of damage to the optic nerve. In mild glaucoma, damage to the optic nerve may be asymptomatic. As damage increases, patients begin to experience difficulty with peripheral vision, contrast sensitivity, glare, adjustments between light and dark, and clear central vision. In its most severe form, glaucoma results in total, irreversible blindness.
Treatments for OAG focus on the reduction of intraocular pressure (IOP), which secondarily prevents the worsening of visual field loss and may prevent visual impairment and blindness. When deciding among medications and laser and incisional surgeries, a clinician may perform a patient-specific risk-benefit analysis to determine which intervention is most appropriate, given the stage of disease and the risk of progression. Unless contraindicated, clinicians commonly initiate therapy with pharmacologic agents.
Conclusion
In patients with OAG, current evidence suggests that medications and laser and incisional surgeries are effective in lowering IOP. Among medications, the prostaglandin analogs are consistently superior to the other classes in terms of their IOP-lowering ability and adverse effect profile. Laser trabeculoplasty (using an argon laser, selective laser trabeculoplasty, or a diode laser) has been shown to lower IOP in patients with OAG, regardless of the type of laser used. Both topical medications and laser trabeculoplasty similarly decrease the risk of visual field loss or optic nerve damage. With regard to incisional surgeries, trabeculectomy lowers IOP more than nonpenetrating surgical procedures like viscocanalostomy and deep sclerectomy, and pressure reductions are enhanced when trabeculectomy (but not other surgical methods) is performed with mitomycin-C. Patients treated medically and/or surgically (trabeculoplasty or trabeculectomy) were less likely to experience progression of visual field loss and optic disc damage than patients who did not receive treatment.
In general, harms from medications do not threaten vision and commonly consist of conjunctival hyperemia and ocular irritation. The possible complications of surgery are more significant than medications and may include infection, bleeding, cataract formation, choroidal effusions, hyphema, and flattening of the anterior chamber. These adverse effects are more common in trabeculectomy than in nonpenetrating surgeries and may be increased in the presence of mitomycin-C.
Current evidence does not address a direct link between reductions in IOP, visual field loss, or optic nerve damage and reductions in visual impairment or vision-related quality of life. The lack of a demonstrated direct link should not be interpreted to mean that reductions in IOP, visual field loss, or optic nerve damage are not important for reducing visual impairment or maintaining vision-related quality of life, but rather that studies demonstrating this direct linkage are not available. The time required to establish relative differences in patient outcomes requires studies with lengthy followup, which are not currently available.
Clinical Bottom Line
Patient-Related Quality of Life
Evidence from included studies did not address a direct link between treatments for OAG and relative changes in patient-reported outcomes such as vision-related quality of life due to the unavailability of studies with sufficiently long-term followup. Included studies gave the following results:
- In two studies of medical interventions, patients preferred the medication that was administered less frequently.
- According to the Collaborative Initial Glaucoma Treatment Study, the fear of blindness in newly diagnosed patients (34%) was significantly reduced 5 years after medical or surgical treatment (11%).
Gaps in Knowledge
- A direct association between treatment for OAG and visual impairment and/or patient-reported outcomes needs to be established.
- Additional evidence is needed on the relative risks and benefits of current medical and surgical treatments for OAG
What To Discuss With Your Patients and Their Caregivers
- The different types of treatment for glaucoma
- The benefits and adverse effects of medicines, laser treatments, and surgeries for OAG
- The severity of the patient's glaucoma and need for treatment
- The importance of adherence to medicine regimens
- The importance of regular and consistent followup with an ophthalmologist or glaucoma specialist to monitor disease progression over time
- Patient preferences regarding the types of treatment
- The cost of medicines and surgical treatments
Resource for Patients
Treatments for Open-Angle Glaucoma, A Review of the Research for Adults is a free companion to this clinician research summary. It can help patients talk with their health care professionals about the many options for treating OAG. It provides:
- Explanations of glaucoma and its causes
- Explanations of medical and surgical treatments
- Current evidence of the effectiveness and adverse effects of different treatments
- Questions for patients to ask their doctor
Ordering Information
For electronic copies of Treatments for Open-Angle Glaucoma, A Review of the Research for Adults, this clinician research summary, and the full systematic review, visit www.effectivehealthcare.ahrq.gov/glaucomatreatment.cfm. To order free print copies of this clinician research summary, call the AHRQ Publications Clearinghouse at 800-358-9295.
Source
The information in this summary is based on Treatment for Glaucoma: Comparative Effectiveness, Comparative Effectiveness Review No. 60, prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. HHSA 290-2007-10061-I for the Agency for Healthcare Research and Quality, April 2012. Available at www.effectivehealthcare.ahrq.gov/glaucomatreatment.cfm. This summary was prepared by the John M. Eisenberg Center for Clinical Decisions and Communications Science at Baylor College of Medicine, Houston, TX.
Publication Details
Author Information and Affiliations
Authors
John M. Eisenberg Center for Clinical Decisions and Communications Science1.Affiliations
Publication History
Issued: February 14, 2013.
Copyright
Publisher
Agency for Healthcare Research and Quality (US), Rockville (MD)
NLM Citation
John M. Eisenberg Center for Clinical Decisions and Communications Science. Comparisons of Medical, Laser, and Incisional Surgical Treatments for Open-Angle Glaucoma in Adults. 2013 Feb 14. In: Comparative Effectiveness Review Summary Guides for Clinicians [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2007-.