European Expert Meeting on Progression

September 11, 2004, Cap d'Antibes, France

Top-Ten Session I

Roger Hitchings on 'What are the phenotypic characteristics to suggest that glaucoma progression is likely?'

• Ocular hypertension
  1. Reduction in the sector rim area.
  2. Para-papillary atrophy.
  3. Senile sclerotic discs.
  4. Retinal nerve fibre layer defect.
  5. Swap defect.
  6. Asymmetry between the optic disks.
• POAG
  1. Optic nerve head haemorrhage.
  2. Retinal vein occlusion.
  3. More severe MD in visual fields.
  4. Fixation threat.
  5. Para-papillary atrophy.
• Other points
  1. Form and function dissociation common in both OHT and POAG.
  2. Greater abnormality in form occurs in 'early glaucoma'.
  3. For a single abnormality identify base line phenotype and follow up annually.
  4. For ocular hypertension plus one other abnormality consider intraocular pressure reduction.
  5. For two abnormalities and normal intra ocular pressure, investigate further for normal pressure glaucoma and observe.
  6. New techniques such as optic nerve head imaging with the red end of the visible spectrum may give additional details.
  7. Retinal oximetry may indicate the optic nerve head at risk.
     
     

Top-Ten Session II

Anders Heijl on 'Follow-up of Progression'

• Progression increases the risk of serious disability.
• To detect and quantify progression provide basis for future management.
• The individual rate of progression is the most important for glaucoma management decisions.
• Recent randomized trials have shown that about half of glaucoma patients will show progression in 5 years, and most in 10 years.
• Risk factors for progression are factors leading to a higher rate of progression.
• The most important barrier to detect progression is variability, with respect to structure as well as function.
• Today there is no good agreement between structure and function measures and it is difficult to translate structural changes into visual function and quality of life.
• It is important to examine the nerve clinically at each visit, not
  to relay solely on imaging devices. Photos are important to set the baseline and to have long-term follow-up of early development.
• New imaging techniques are promising, but yet HTR II is today the only technique where we have longitudinal data for use in clinical setting. However, as we do not have yet algorithm to apply to HRT to detect change, we are better off to use both structure and function to detect and follow progression.
• For functional testing: choice of baseline tests are critical, learning effects are important, at least 3-5 tests are needed to show progression after baseline is established. White on white perimetry still gives most reliable data.
• The patient's binocular field can be obtained from merging the fields from both eyes, and is best related to patient perception.
• Recommendations for glaucoma management:
  1. get good baseline data for each patient.
  2. get good quality data (images/fields).
  3. establish risk factors for each individual patient.
  4. first 2 years, see the patient 3-4 times/year, look at the nerve, measure VF at least 2-3 times.
  5. when the individual rate of progression is established, adjust visits intervals and consider changing treatment.

Top-Ten Session III

Clive Migdal on 'Treatment and Progression'

• Management of glaucoma must strive to prevent progression to advanced visual function loss.
• Management of glaucoma should be tailored according to each individual as each individual patient has very variable rate of progression.
• Recommendation to use EGS guidelines and combine the available evidence with 'common' sense.
• Base initial treatment of newly diagnosed patients on risk factors and thorough follow-up, consider life expectancy.
• Individual risk assessment for each patient is based on prediction of future progression allowing for better treatment decisions.
• Most important risk factors:
  1. Age (10 years increase in age gives 40% higher risk for progression).
  2.  Initial IOP level.
  3. Amount of visual damage (Mean Deviation).
  4. Exfoliation.
  5. Disk Haemorrhages.
  6. Thin cornea in OH patients; still debated whether CCT is an independent risk factor.
• A 24 hour profile of IOP will optimize decision making. Best outcome if patients lie down to have their IOP taken. Calibrate tonometer regularly.
• Level of initial IOP reduction important for outcome of treatment (EMGT).
• Lower IOP slows onset and progression of glaucoma; most effective treatment reduces IOP fluctuations providing a flat diurnal curve.
• We are under-diagnosing and under-treating the more advanced patients.
• For the progressing patient, a lower level of IOP is important for halting disease progression; for the patient without risk factors and without progression, wait and follow patient before treatment is initiated.
• In EMGT it was shown that the amount of VF defects a patient had at the first visit to the clinic can be very severe, mean MD of the worst eye was -16dB, (bilateral glaucoma). Better detection of glaucoma is necessary.