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Comment by Felipe Medeiros 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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King et al. performed a nice review on the existing evidence with regard to the primary choice of treatment in patients with advanced glaucoma. As patients with advanced disease are potentially at high risk for blindness and functional impairment, it has been suggested that primary surgery should be offered as the first treatment step instead of the conventional approach of escalating medical therapy. Patients with advanced damage may require lower target IOPs and perhaps a more stable IOP profile over time. This could be related to a higher susceptibility of a severely damaged optic nerve to further losses or it could simply reflect our current methods of assessing visual function. Due to the logarithmic scaling of visual field measurements, losses at the end of the spectrum will be maximized compared to losses at the early stages, giving the impression of faster progression in patients with more advanced damage.

However, whatever the reasons might be, further deterioration in the visual field of patients with severe damage, even if relatively small, may translate in further decreases in quality of life. Despite these concerns, there is insufficient evidence to suggest that primary surgery would result in better clinically relevant outcomes in patients with severe glaucoma compared to standard medical therapy.

Most of the previous studies comparing these two methods were performed before the availability of newer medications, such as prostaglandin analogues, which have dramatically improved the efficacy of medical therapy in glaucoma. A recent report from the CIGTS, however, suggested that patients with severe disease at baseline (MD lower than -10dB) would potentially benefit from primary surgery compared to medical treatment. However, this effect was only significant after seven years of follow-up and resulted in an average difference of only 1dB between the two groups. This might be relevant for a young patient who presents with advanced damage, but perhaps not so much for a patient with the same damage but with reduced life expectancy.

Due to the logarithmic scaling of visual field measurements, losses at the end of the spectrum will be maximized compared to losses at the early stages, giving the impression of faster progression in patients with more advanced damage

Based on the absence of conclusive evidence from the literature, the authors concluded that there is no reason at the moment for clinicians to change their clinical practice until further evidence is demonstrated. This seems to be reasonable recommendation in view of the paucity of available data. Although surgical therapy has the potential of providing more sustainable lowering of the IOP with less fluctuations over time, it has also an increased potential for vision-threatening complications compared to medical therapy. Finally, the authors also pointed out the need for a randomized trial comparing medical versus primary surgical therapy specifically in patients with advanced disease emphasizing the importance of achieving adequate power to address issues of clinical outcome, safety and quality of life in this population.

There is insufficient evidence to suggest that primary surgery would result in better clinically relevant outcomes in patients with severe glaucoma compared to standard medical therapy

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