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The challenges of glaucoma management

ByL. Jay Katz, MD

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L. J. Katz, MD

Glaucoma is a prevalent disease most ophthalmologists have to face regularly. Estimates show that nearly 4 million adults aged 40 years or older have glaucoma. The average age at onset is 54, with about two-thirds of patients having glaucoma for 10 years or longer. Many patients go untreated for up to 20 years. ^1,2 Worldwide statistics show that up to 6 million people are blind from glaucoma. In the United States the number is between 100,000 and 200,000.³

There are various reasons why people go blind from glaucoma, such as not having access to health care, being underinsured or noninsured and not having the money to pay for therapy. Also, patients who do not adhere to therapy or advice given by their ophthalmologist are at risk. Another issue is that ophthalmologists do not always apply adequate therapy to patients. It is difficult balancing the right amount of treatment to keep patients stable, and there are concerns about the potential ramifications of treating a patient with added medication.

The American Academy of Ophthalmology (AAO) has stated the number of patients with glaucoma is going to rise dramatically, while the number of ophthalmologists will not rise fast enough to keep up with the demand for care.⁴ Current ophthalmologists will be forced to carry the burden of care for this increase in glaucoma.

The cost to society is estimated at about $2 billion per year to care for patients with severe visual impairment.⁵ The goal of ophthalmologists is to identify these patients, diagnose their condition and treat them adequately.

Treatment

Current treatment of glaucoma is to lower intraocular pressure (IOP). Multiple studies have recommended a ceiling IOP for glaucoma patients, and AAO recommended that 20% to 30% IOP reduction should be the first step for ophthalmologists treating glaucoma based on those studies.⁶ AAO recommended basing the exact percentage of IOP reduction on patient risk factors. There is a debate among ophthalmologists as to whether a more specific target IOP should be suggested.

There are new considerations that make target pressures more complex, such as daily fluctuation of IOP. A study conducted nearly 10 years ago found that not only is maximum IOP an important risk factor in glaucoma progression, but also the fluctuation of IOP might be an independent factor for progression of glaucoma.⁷ The study recommended close monitoring of IOP throughout the day, readjusting target IOP and readjusting the range of IOP depending on the course the patient takes.

Several other studies have found both short-term and long-term IOP fluctuation can have an effect on patient outcomes. For example, the Advanced Glaucoma Intervention Study conducted a post-hoc analysis of IOP fluctuation and stability of the visual field.⁸ The study compared patients who had an IOP fluctuation of 3 mm Hg or more in follow-up visits with a group of patients who had IOP fluctuations of less than 3 mm Hg. The group of patients with the greater IOP fluctuation had a worse visual field compared with the group of patients who had a lower IOP fluctuation.

Other studies, however, refute the results of studies that show IOP fluctuation has an effect on the visual field. The Early Manifest Glaucoma Treatment Study showed no correlation between high IOP fluctuation and visual field loss.⁹ More studies have to be conducted to show that IOP fluctuation is an independent factor in glaucoma progression.

Conclusion

Glaucoma is still a leading cause of blindness worldwide. An understanding of where to keep peak IOP values and keeping IOP fluctuation to a minimum can help in the success of glaucoma treatment. Ophthalmologists can better treat patients by understanding how to treat individual patients and providing guidelines to patients on an individual basis.

References

1. The 2002 Gallup Study of Eye Health: Survey of Glaucoma. Princeton, NJ: Multi-Sponsor Surveys; 2002.
2. The Eye Disease Prevalence Research Group. The prevalence of diabetic retinopathy among adults in the United States. Arch Ophthalmol. 2004;122:552-563.
3. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol. 2006;90:262-267.
4. American Academy of Ophthalmology. Primary Open-Angle Glaucoma, Preferred Practice Pattern. San Francisco: American Academy of Ophthalmology, 2005. Available at: www.aao.org/ppp.
5. Lee PP, et al. A multicenter, retrospective pilot study of resource use and costs associated with severity of disease in glaucoma. Arch Ophthalmol. 2006 Jan;124(1):12-19.
6. American Academy of Ophthalmology. Preferred practice patterns. http://www.aao.org/education/guidelines/ppp. Accessed October 23, 2007.
7. Asrani S, Zeimer R, Wilensky J, Gieser D, Vitale S, Lindenmuth K. Large diurnal fluctuations in intraocular pressure are an independent risk factor in patients with glaucoma. J Glaucoma. 2000 Apr;9(2):134-142.
8. Nouri-Mahdavi K, Hoffman D, Tannenbaum DP, et al. Predictive factors for glaucomatous visual field progression in the Advanced Glaucoma Intervention Study. Ophthalmology. 2004;111:1627-1635.
9. Bengtsson B, Leske MC, Hyman L, et al. Fluctuation of intraocular pressure and glaucoma progression in the Early Manifest Glaucoma Trial. Ophthalmology. 2007;114:205-209.