Standard, single-treatment strategy sufficient for most patients with untreated glaucoma
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Key takeaways:
- The annual rate of progression of visual field damage was faster in the monotherapy group but not significantly.
- Differences in visual outcomes were more pronounced among patients with a higher baseline IOP.
An escalating monotherapy regimen was just as effective as multitherapy for most patients with untreated glaucoma, although those with higher baseline IOP may benefit from more intensive treatment, according to a study conducted in Sweden.
The Glaucoma Intensive Treatment Study assessed the effect of a multitherapy regimen that included selective laser trabeculoplasty vs. traditional monotherapy in patients with early or moderate untreated open-angle glaucoma.
“The intention was to mimic ordinary clinical care insofar as possible,” Boel Bengtsson, professor of experimental ophthalmology at Lund University in Sweden, and colleagues wrote in American Journal of Ophthalmology. “There were no IOP inclusion limits; changes in treatment were allowed, as were additional visits when deemed necessary; and there was no masking.”
The researchers enrolled 242 patients (median age, 68 years; median baseline IOP, 24 mm Hg), who were randomly assigned to a single IOP-lowering medication (n = 118; 143 eyes) or to intensive treatment with IOP-medications from three classes, followed by SLT 1 week after starting medical therapy (n = 124; 155 eyes). Participants were monitored for 5 years, with clinical visits tapering each year.
The primary outcome was final visual field status.
According to results, the median visual field index (VFI) at projected end of life was 79.3% in the monotherapy group compared with 87.1% in the multitherapy group, a difference that did not reach statistical significance. Among patients with higher baseline IOP, the VFI was 74.1% and 85.8%, respectively (P = .07).
The researchers also found that the overall median rate of progression of visual field damage was faster in the monotherapy group, although the difference was not statistically significant. Similarly, although patients with higher baseline IOP experienced greater effect with multitherapy, the difference reached “only borderline” statistical significance.
In addition, more patients in the monotherapy group reached the criterion for a visual field definite progression during the 5-year follow-up (21% vs. 11%; P = .03).
“It is important to bear in mind that the often-recommended escalating strategy, starting with monotreatment, was just as effective as the initial intensive treatment in participants with lower baseline IOP, and thus was sufficient in a large proportion of glaucoma patients,” Bengtsson and colleagues wrote.
Perspective
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When initiating treatment for glaucoma, I have always favored a stepwise addition of therapy over a multiple-medication approach for most patients.
While it is reassuring that this study did not find a statistically significant difference between the stepwise and the multi-treatment protocols, the results suggest that monotherapy with escalation may not provide the best outcome for patients with untreated an IOP of 24 mm Hg or higher. In this subgroup, there was borderline significance in favor of the initially intensive protocol with regard to lower rates of progression, fewer event-based progression occurrences and a higher projected end-of-life VFI.
Conversely, patients with an IOP lower than 24 mm Hg showed negligible differences between either treatment arm, implying that a stepwise treatment paradigm is noninferior for “normotensive” patients.
It is unclear to me whether the benefits realized in the higher IOP subgroup benefited more from initially aggressive IOP control or from the inclusion of SLT in the intensive treatment arm as a component of the protocol. There is evidence from the LiGHT trial that SLT offers similar long-term benefits over medication therapy with regards to similar visual field measurements for progression.
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