Treatment may be delayed for patients with early glaucoma
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If glaucoma is diagnosed early, treatment for the disease can be delayed, as the treatment effect is usually modest and the patient has time to be treated at a later point.
“In summary, don’t treat the early glaucoma patient. The definition of early glaucoma is vague. There is time to treat later, the treatment effect is modest, there is no evidence that treatment affects quality of life, most patients won’t live long enough to lose important vision, and treatment has side effects,” Henry Jampel, MD, said at the virtual American Glaucoma Society annual meeting.
Of course, there are exceptions to the rule. If the patient’s IOP is very elevated, if they cannot stand the idea of having an untreated disease or if the patient is worsening, then they should be treated, he said.
The Early Manifest Glaucoma Trial (EMGT) showed the effectiveness of treatment in early glaucoma is only modest. At 6 years, 49% of the treated group worsened compared with 63% of the untreated group.
“This leads to a number needed to treat of seven. In other words, one needed to treat seven early glaucoma patients to see a beneficial effect in one,” Jampel said.
In the United Kingdom Glaucoma Treatment Study (UKGTS), patients with early glaucoma were randomly assigned to receive latanoprost or placebo. At 2 years, 15% of the treated group worsened compared with 25% of the untreated group, for a number needed to treat of 10.
The EMGT results also showed similar quality of life outcomes at 3 years in treated and untreated patients, for both the composite and subscale scores in the NEI VFQ-25.
Data from a 2008 study from Broman and colleagues in Investigative Ophthalmology and Visual Science showed most patients with early glaucoma do not live long enough to go blind. Compared with the average age of which a glaucoma patient died, the worst-case scenario for African patients showed the average time from glaucoma diagnosis until death was 15 years. For other ethnicities it was less than 15 years, Jampel said.
Additionally, all glaucoma treatments can have side effects. Results from the EMGT showed that the onset or progression of cataract was higher in the treated group compared with the control group, he said.
“Is it ethical to not treat the early glaucoma patient? I would argue yes. The decision to treat should be based upon an analysis of the risk and benefits of the treatment, not just the benefits. The EMGT and the UKGTS do demonstrate the benefit of treatment, but they did not offer a risk-benefit analysis,” he said.
Any decision to observe or treat should involve the patient in the decision-making process, Jampel said.
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Jampel H. Early glaucoma should not be treated. Period. Presented at: American Glaucoma Society annual meeting; March 4-7, 2021 (virtual meeting).
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