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Do you treat glaucoma suspects?
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Treatment means patients will not be lost to follow-up
 Anton Hommer |
“Glaucoma suspect” describes a person who has borderline signs of glaucoma. It might be the appearance of the optic disc or retinal nerve fiber layer. If only the pressure is elevated, we call it ocular hypertension. The decision of treating or not treating these patients depends on the risk profile. I always prescribe treatment (preferably with prostaglandins or, as a second choice, beta-blockers) when IOP approaches 30 mm Hg, even with normal pachymetry and no other risk factors. I also consider a family history of glaucoma as a good reason to treat. But there are also other patient-related and physician-related factors that, in my opinion, are equally important in the decision.
We all agree that regular monitoring of a glaucoma suspect is mandatory. If you are sure that your patient trusts your judgment, serenely accepts to wait and see, and will come back for regular visits, treatment can be postponed to when it is definitely needed. But not many patients react in this way to the uncertainty of a “suspect” disease. Some of them, if you send them back without any treatment, get very anxious and afraid to become blind. Others, at the opposite end of the spectrum, underestimate their condition and do not come back for visits. In all these patients, the benefits of treatment outweigh the disadvantages. Medications nowadays are safer; we even have preservative-free options that can conveniently be taken in once-a-day doses. They have very few systemic side effects, and so there are fewer concerns about treating. It is known that patients are more compliant with screening schedules if they are on medical therapy, and this, together with the appropriate information on the critical importance of a regular follow-up, will work in favor of not losing and regularly monitoring glaucoma suspects.
Anton Hommer, MD, is a senior consultant, Hera Hospital, Vienna, Austria.
Eye needs to show clear evidence of progression
 Masaki Tanito |
There are several reasons for not treating a glaucoma suspect. First of all, the possible side effects of medications in patients who possibly do not need them. Then, the inconvenience of time-consuming everyday instillations and the burden of more frequent visits to the clinic. Last but not least, glaucoma medications are expensive. In Japan, public insurance covers 70% of the cost, while patients need to cover 30%.
We must take into account that all the problems associated with the use of medications are going to be there for life. Once medications are started, there are very few chances to quit them. Bearing this in mind, we never rush into treatment. The true priority in the case of a glaucoma suspect, for both patients and physicians, is not to miss a possible conversion to glaucoma, and therefore I perform sequential examinations every 6 to 12 months. I consider treatment, usually with topical prostaglandins, only when the risk of developing glaucoma is remarkably high, ie, when there is glaucoma in the fellow eye or when there is a clear rise of IOP to more than 23 mm Hg. In the Japanese population, the average IOP is 14.5 mm Hg, and most cases of glaucoma suspects are expected to show no IOP rise because of the high rate of normal-tension glaucoma. Otherwise, I will not start any therapy until the eye shows clear evidence of visual field decline progression by sequential visual field testing or morphological changes such as rim thinning, widening of RNFL defect or RNFL thinning.
Masaki Tanito, MD, PhD, is an associate professor, Department of Ophthalmology, Shimane University, Shimane, Japan.