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``Doctor will my eye condition get worse?``
What is the diagnosis (OHT vs NTG vs POAG early or late ?)
Does the patient have the published risk Factor for progression?
Risk of Progression
Diagnosis Risk of progression with no Rx (%)
Risk of progression with Rx (%)
OHTOHT study 5 yrs
NTG(CNTG study 6 yrs )
Early POAG(EMGS study 6 yrs )
Advanced POAG(AGIS-7 yrs)
Ocular hypertension treatment study
Aim To determine if glaucoma drops delays
or prevents glaucoma in ocular hypertensives
Arch Ophthalmol 120: 701-713, 2002.
OHTS - methods
RCT of 1600 patients IOP 24-32mmHg in one eye and 21-
32 in other eye Normal discs and fields
Drops prescribed to achieve IOP of ≤24mmHg AND at least 20% drop from baseline
Risk of Progression
Diagnosis Risk of progression with no Rx (%)
Risk of progression with Rx (%)
OHTOHT study 5 yrs
9.5 4.4
NTG(CNTG study 6 yrs )
Early POAG(EMGS study 6 yrs )
Advanced POAG(AGIS-7 yrs)
OHTS conclusions
Factors associated with progression ``I treat if:``
Older age High CDR (vertical or horizontal) > 0.4 High PSD IOP Thinner cornea
Risk of Progression
Diagnosis Risk of progression with no Rx (%)
Risk of progression with Rx (%)
OHTOHT study 5 yrs
NTG(CNTG study 6 yrs )
Early POAG(EMGS study 6 yrs )
Advanced POAG(AGIS-7 yrs)
NTGS - methods
239 patients recruited
Uni or bilateral NTG as defined by IOP <21 in 10 baseline measurements
AND Glaucomatous cupping Defined type and severity of field loss
NTGS - methods
Randomised immediately if VF defect threatening fixation Previously documented disease
progression
Others randomised when evidence of progression
NTGS
145 (of 239) patients randomised One eye randomised to
Treatment Drops, ALT or surgery to achieve 30%
reduction in IOP No treatment until evidence of
progression Other eye could be treated in this group
NTGS results
30% drop achieved in half without surgery
Once 30% drop achieved rate of progressive field loss was lower than group that did not receive treatment (after allowing for cataract effect which was higher in treated group)
NTGS results
Rate of progression in untreated NTG highly variable
Half did not progress on VF in 5 years Factors associated with progression
Female Migraine Disc haemorrhages on presentation
NTGS conclusions
Overall, lowering IOP in NTG slows progression.
However, over half of patients did not progress without treatment at 5 years.
Risk of Progression
Diagnosis Risk of progression with no Rx (%)
Risk of progression with Rx (%)
OHTOHT study 5 yrs
NTG(CNTG study 6 yrs )
60 20
Early POAG(EMGS study 6 yrs )
Advanced POAG(AGIS-7 yrs)
• Factors associated with progression• ``I am aggressive if:``–Female–Migraine–Disc haemorrhages on presentation
Risk of Progression
Diagnosis Risk of progression with no Rx (%)
Risk of progression with Rx (%)
OHTOHT study 5 yrs
NTG(CNTG study 6 yrs )
Early POAG(EMGS study 6 yrs )
Advanced POAG(AGIS-7 yrs)
Early Manifest Glaucoma Trial•Compared immediate treatment
versus no (or delayed) treatment for patients with newly diagnosed POAG
•Diagnosis based on reproducible visual field defects
• Included NTG
EMGT
•255 patients•Randomised to ▫ ALT and betaxolol▫No treatment
• If IOP >25mmHg in treated (>35 untreated)→ Latanoprost added
• If remains high → individualised treatment
EMGT - results
Over 6 years 62% untreated versus 45% of treated
group progressed Median time to progression 66 months
treated versus 48 months untreated
Risk of Progression
Diagnosis Risk of progression with no Rx (%)
Risk of progression with Rx (%)
OHTOHT study 5 yrs
NTG(CNTG study 6 yrs )
Early POAG(EMGS study 6 yrs )
62 45
Advanced POAG(AGIS-7 yrs)
Early POAG risk factors (EMGS)
Baseline factors Pseudoexfoliation Older age Higher IOP Worse mean
deviation
Follow up factors IOP
Each 1mmHg reduction from baseline reduced risk of progression by 10%
Disc haemorrhages
Early POAG risk factors (EMGS)
• Factors associated with progression• ``I am aggressive if:`` Pseudo exfoliation
Bilateral disease Older age Higher IOP Worse mean
deviation Disc hemorrhage
Risk of Progression-Advanced glaucoma
Diagnosis Risk of progression with no Rx (%)
Risk of progression with Rx (%)
OHTOHT study 5 yrs
NTG(CNTG study 6 yrs )
Early POAG(EMGS study 6 yrs )
Advanced POAG(AGIS-7 yrs)
Advanced Glaucoma Intervention Study
Aim To assess the outcome of sequences of
laser and surgical interventions in eyes that have failed on medical treatment
AGIS
•POAG, uncontrolled with drops•Randomised to 2 groups
1. Trab → ALT → Trab2. ALT → Trab → ALT
Medical treatment as required789 patients followed up for at least 5
years
AGIS results
Vision better in blacks if had ALT first In whites
Vision better in laser group for first 4 years
Then better in surgery group
AGIS results
Side arm looked at IOP and VF loss
Divided into 2 groups IOP <18mmHg at 100% visits (mean =
12.3mmHg) = little VF deterioration IOP <18mmHg at <50% of study visits
(mean = 20.2mmHg) = significantly more VF deterioration
AGIS conclusions
Relationship between low IOP and VF loss remains important finding
In advanced glaucoma, lowering IOP to low teens means most will not progress
Risk of Progression-Advanced glaucoma
Diagnosis Risk of progression with no Rx (%)
Risk of progression with Rx (%)
OHTOHT study 5 yrs
NTG(CNTG study 6 yrs )
Early POAG(EMGS study 6 yrs )
Advanced POAG(AGIS-7 yrs)
Not Known 30 VA 14 VF(IOP <15mmhg)
Factors associated with progression ``I am aggressive if:``
Older age Lower education Good VA DM High IOP > 18 IOP fluctuation
AGIS conclusions
Collaborative Initial Glaucoma Treatment Study (CIGTS)
Does not provide direct evidence that IOP has an impact on glaucomatous progression, but you need to know about it…
AIM:to assess the effect on early-diagnosed OAG of initial Tx with either topical meds or trab
CIGTS - Methods
Prospective RCT OAG (POAG, Pigmentary, PEX) N=607 Randomized → Medical management
↘ Trabeculectomy IOP target customized for each
patient Primary End Point: progression of VF
loss
CIGTS – Results at 5yrs
Medical Treatment
Surgical Treatment
IOP reduction 28mmHg→17-18mmHg
27mmHg→14-15mmHg
Progression at 5 years
No progression No progression
• Surgical group is at increased risk of visual loss initially but by 4yrs both groups are comparable
CIGTS summary
Surgery resulted in Lower IOP More cataract More ocular side effects Initial ↓ vision Initial ↓ visual field
Diagnosis Risk of progression with no Rx (%)
Risk of progression with Rx (%)
OHTOHT study 5 yrs
9.5 4.4
NTG(CNTG study 6 yrs )
60 20
Early POAG(EMGS study 6 yrs )
62 45
Advanced POAG(AGIS-7 yrs)
Not Known 30 VA14 VF(IOP <15mmhg)
RISK OF PROGRESSIONTHE BEST EVIDENCE SUMMARY
Risk Factors for Progression
Factors OH Glaucoma Glaucoma ProgressionHigher age OHTS AGIS, CIGTS, EMGT
CCT OHTS
C:D ratio OHTS
Diabetes mellitus OHTS AGIS, CIGTS
Disc hemorrhage EMGT , NTGS
IOP (higher) OHTS EMGT
IOP (over f/u) OHTS EMGT
Male OHTS AGIS
PXF EMGT
Race (non-white) OHTS CIGTS
Visual field OHTS EMGT
Glaucoma Risk Calculation Results
Patient Age - - - 65Corneal Thickness - - - 490 micronsIOP - - - 23PSD - - - 1.4Vertical Cup / Disk Ratio - - - 0.7
Risk of developing glaucoma within the next five years.Risk without treatment - - - 41.71 %Risk with treatment - - - 16.68 %
Patient Age - - - 65Corneal Thickness - - - 550 micronsIOP - - - 23PSD - - - 1.4Vertical Cup / Disk Ratio - - - 0.7
Glaucoma Risk Calculation Results
Risk of developing glaucoma within the next five years.Risk without treatment - - - 16.86%Risk with treatment - - - 6.74 %
My “take home messages”
1. Every mmHg helps (EMGT)2. If get IOP very low (12mmHg) most
patients will not progress (AGIS)3. NTG is a funny disease
- Many do not progress- If do – only proven treatment is reducing IOP
4. Not all OHT needs treated – assess risk on individual basis and discuss with patient