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Editors Selection IGR 9-4

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Comment by Keith Barton on:

46501 Treating patients presenting with advanced glaucoma - Should we reconsider current practice?, King AJ; Stead RE; Rotchford AP, British Journal of Ophthalmology, 2011; 95: 1185-1192

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This article presents a timely review of an important area of glaucoma management. The UK National Institute of Clinical and Health Excellence (NICE) published guidelines on the diagnosis, management and delivery of care of patients with chronic open-angle glaucoma (defined as primary open-angle glaucoma plus pigmentary glaucoma and exfoliative glaucoma) and ocular hypertension in April 2009. Among other recommendations, they advised that patients presenting with advanced glaucoma should be offered surgery at presentation. This recommendation probably reflects the regular clinical behavior of many glaucoma subspecialists, but serves to highlight for non-specialists the importance of treating those at a high risk of visual loss, more aggressively than those who are at a low risk. King et al. have looked carefully at a broader range of literature than only the randomized clinical trials that would have been considered by NICE. They conclude that surgery probably offers better IOP and visual field outcomes than medical treatment in patients presenting with advanced glaucoma. However, they admit that this conclusion is based on the balance of probability rather than beyond reasonable doubt, and importantly highlight the need for a randomized clinical trial comparing medication with surgery in such patients.

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