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Merits of treating ocular hypertensive patients debated
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CHICAGO — Recent trials indicate lowering IOP in patients with ocular hypertension can delay their conversion to glaucoma. But, with this information in hand, should the clinician treat most of these patients with IOP-lowering medications or treat only those at high risk of progressing to glaucoma?
This issue was debated by two glaucoma experts here at the Glaucoma Subspecialty Day preceding the American Academy of Ophthalmology meeting.
David L. Epstein, MD, argued that “we need to treat more patients rather than less.” Paul R. Lichter, MD, took the view that “we need to decide where to draw the line” and treat only those ocular hypertensive patients with known risk factors for glaucoma, such as ethnicity or family history.
Dr. Epstein, arguing for treating most ocular hypertensive patients, said that he tries to practice by the Golden Rule: “Treat others as you would treat your own eye.”
“IOP is not a risk factor for glaucomatous damage, it is a causative factor,” he said.
Making an analogy with the treatment of systemic hypertension, Dr. Epstein noted that five patients with borderline blood pressure elevation are treated in order to protect one patient, because that one patient cannot be identified prospectively.
Similarly, he said, “We may need to treat five to save one” from conversion to glaucoma.
Taking the view that only patients with ocular hypertension with known risk factors for glaucoma should be treated, Dr. Lichter noted that the Ocular Hypertension Treatment Study suggested that 20 patients must be treated to prevent one conversion to glaucoma. He said following that strategy, the negative effects of medication, such as expense, inconvenience and side effects, will be experienced needlessly by 95% of the treated patients.
Responding to Dr. Epstein’s remark about the Golden Rule, Dr. Lichter said, “If it were my eye, I would not want you to treat me, unless I were at high risk.”
“We use a decision tree to decide who to treat,” Dr. Lichter said, considering such risk factors as age, baseline IOP, ethnicity and family history.
“There is no evidence that treating most ocular hypertensive people will help them,” Dr. Lichter said.