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Comment by Jeffrey Liebmann 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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The management of patients who are discovered to have advanced glaucomatous optic neuropathy and visual field loss at the time of initial presentation represents a variety of challenges. For many of these individuals, the presence of advanced injury suggests not only a greater susceptibility to glaucoma damage, but also more rapid past progression, increased risk for future glaucoma progression and, because of fewer healthy retinal ganglion cells and a damaged visual field, higher risk for progression to functional impairment and blindness. In the present article, King, Stead and Rotchford discuss recent NICE guidelines issued for England and Wales that suggest that patients with advanced diseased should undergo primary surgery as the initial treatment of their disease. The authors conclude that there is insufficient evidence to warrant a radical departure from the traditional medical, laser surgery, and incisional surgery sequence utilized by most ophthalmologists in this setting.

In eyes with advanced glaucoma at presentation, a low IOP should sought rapidly and efficiently, with the intent of seeking and maintaining a low target IOP

Although a radical departure from traditional understanding and treatment of disease is anathema to the conservative nature of most physicians, it is important to constantly reassess diagnosis and treatment paradigms in the search for better ways to manage disease.

Treatment of a life-long disease such as glaucoma is complex and physician decision-making typically requires assessment of wide variety of disparate factors. These variables include not only the clinical factors listed above (disease stage, risk factors, rate of progression, etc.), but also patient quality of life and life expectancy. Underestimation of life expectancy is particularly deleterious to patients with glaucoma because even a slowly progressive disease can lead to extensive visual impairment, particularly when the amount of damage when the disease is discovered is advanced.

What can we learn from this article and how can we improve our treatment paradigms? First, the scientific literature suggests that treatment for eyes with advanced glaucoma can be extremely effective, but only if intraocular pressure reduction is significant and long-lasting. This should dispel the notion that these patients are doomed to blindness. Second,incisional surgery offers the best chance, although with caveats, for achieving this goal. Surgeons are reticent to utilize surgery early in the course of treatment because of the risk of complications and lack of patient acceptance.

How can we find a middle ground that will allow for a better approach? Rather than a simplified approach, such as 'surgery for everyone', one could argue that the main goal of intervention should be two-fold: to seek a low target IOP and try to achieve it in an expeditious meaningful fashion.

Given that some patients with advanced disease have very significant IOP reductions with even a single medication, most ophthalmologists would not want to proceed to surgery without offering these individuals at least a brief trial of topical medication to see if he or she has an outstanding response. All too often, however, ophthalmologists monitor therapy or defer more aggressive intervention if the IOP hovers above the target. This is probably not good practice. In eyes with advanced glaucoma at presentation, a low IOP should sought rapidly and efficiently, with the intent of seeking and maintaining a low target IOP. If peak IOP continues to exceed the target, advancement to incisional surgery should be considered, even if this is relatively soon after diagnosis.

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