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Editors Selection IGR 10-3

Glaucoma Screening and Detection: Recommendation Statement

Comment by Fotis Topouzis on:

54878 Screening for glaucoma: U.S. Preventive Services Task Force Recommendation Statement, Moyer VA, Annals of Internal Medicine, 2013; 159: 484-489

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The U.S. Preventive Service Task Force (USPSTF) published an update of the 2004 recommendation on screening for glaucoma. The USPSTF reviewed evidence on the benefits and harms of screening for glaucoma and of early glaucoma surgical and medical treatment. In this regard they also considered evidence on the accuracy of screening tests.

The USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for glaucoma.

Specifically the authors found inadequate evidence on the accuracy of screening and highlighted the lack of an established gold standard against which individual screening tests can be compared. In addition, they found inadequate evidence that screening for or treatment of increased IOP or early primary open-angle glaucoma (POAG) reduces the number of persons who will develop impaired vision or quality of life. On the other hand the authors found no direct evidence on the harms of screening, but they found convincing evidence that treatment results in harms including eye irritation from medications and risk for complications from surgery. While assessing harms of screening the authors pointed out that screening is associated with a risk for false-positive and false-negative results, but the magnitude of this risk is unknown because of the high variability in reported test sensitivity and specificity.

high-quality evidence for screening would ideally come from randomized, controlled trials of routine (or targeted) screening vs standard care with long-term follow-up

While assessing the balance of benefits and harms of screening for glaucoma, one should consider the natural history of glaucoma which is heterogeneous and still poorly defined in our days. In addition, POAG does not progress in some patients or in others progression is so slow that it never comes to significant visual impairment during life-time. The size of these subgroups is uncertain. Further, progression of early glaucoma to visual impairment cannot be predicted. The above were considered by the USPSTF. However, the psychological impact as a potential harm was not considered by the USPSTF. In addition, although the cost of screening was considered in their assessment, the cost of entering the false-positives in health care system (including examination cost and treatment cost) was not considered. Finally, the recommendation should ideally be stage specific and high risk groups specific. This approach would provide better assessment of the balance of benefits and harms of screening for POAG. As the authors stated, high-quality evidence for screening would ideally come from randomized, controlled trials of routine (or targeted) screening vs standard care with long-term follow-up.

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