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Increase in glaucoma treatment reduces rate of field progression
Medical treatment escalation or additive laser trabeculoplasty significantly reduces the rate of visual field progression in patients with primary open-angle glaucoma, according to a study.
A large database evaluating the records of patients followed for more than 10 years in four university hospitals in France provided the real-life clinical data for the study.
A total of 171 patients with primary open-angle glaucoma were included. They had undergone a mean of 10 visual field examinations over 5 years before and after medical treatment escalation or additive laser trabeculoplasty to maintain or achieve the target pressure. Patients were freely managed by the clinicians, who decided when additional medications or other treatments were required.
Switching from monotherapy to dual therapy and from dual therapy to triple therapy resulted in an approximately 10% reduction of IOP and a significant decrease of the rate of progression. Escalation to quadruple treatment had no further effect on either IOP or visual field progression. Additive laser trabeculoplasty had comparable effects on IOP and was significantly associated with a decrease in the rate of progression.
Greater IOP reduction was associated with greater decrease of glaucoma progression and vice versa. However, relatively modest IOP reduction had clinically relevant benefits on the visual field. In the medical treatment group, an 11% decrease in IOP was associated with a halved rate of progression, from -0.57 dB/y to -0.29 dB/y.
According to the authors, this study suggests that “some treatment escalation modalities that are sometimes performed by ophthalmologists in clinical practice ... but have not been evaluated to date also could have a beneficial effect.” – by Michela Cimberle
Disclosure: The authors reported no conflict of interest.
Perspective
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In demonstrating that lowering IOP reduces the risk and rate of disease onset and progression, the landmark glaucoma trials have informed our decision-making for nearly 3 decades. Surprisingly, few studies have subsequently examined the impact of augmenting therapy in progressing manifest glaucoma, particularly in the “real world” of daily clinical practice.
In this retrospective review, Aptel and colleagues have shown that escalating treatment significantly slows the rate of visual field deterioration in patients with pretreatment IOPs greater than 21 mm Hg. In fact, a relatively modest 10% decrease in IOP through additional medicine or laser halved the rate of progression. While changes of less than 1.5 mm Hg were of little value, progressively greater benefit was realized with larger pressure reductions, corroborating the conclusion of the EMGT that “every millimeter of mercury counts.”
This analysis may be particularly germane to the profession of optometry in that patients had early to moderate glaucoma (median MD -3.3dB), progression was unequivocal but not catastrophic, and intervention was limited to topical medications and laser trabeculoplasty. Further, while escalating mono- and dual therapy was effective, adding a fourth medication was not, reinforcing the importance of recognizing maximal medical therapy and referring for timely surgical intervention.