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LAGS Meeting: The Rio-Consensus

April 10, 2004, Rio de Janeiro, Brazil

Daniel Grigera

Dancing on a warm night at Ilha Fiscal, surrounded by the marvelous Guanabara Bay, is something to remember. Fortunately, Erik and Caroline (and all of you) still have a chance to tango in Buenos Aires in 2006, at the next LAGS meeting. The Dancing setting a grand scientific program.

Rio nested a carefully prepared Consensus on Ocular Hypertension and on Open Angle Glaucoma.

Methods: topics based on relevant scientific background were presented by Felipe Medeiros and Javier Casiraghi. Interactive multiple-choice questions on these subjects were then posed to a mixed audience of LAGS members and local colleagues. Only LAGS members' answers were considered for the consensus, but everybody was entitled to vote. A consensus was considered reached when a 70% agreement in the answers was obtained. A remarkable consistency in the answers from LAGS members and from the general audience was observed throughout the event.

Consensus conclusions

Ocular hypertension

• Ocular hypertension is defined by the following criteria: a) high intraocular pressure (IOP); b) normal visual fields (VF); and c) optic nerve (ON) head with a normal appearance.
• High IOP in the adult, as an OH criterion, is defined as: IOP > 21 mmHg.
• Normal visual field, as an OH criterion is defined as: normal Standard Automated Perimetry (SAP).
• Normal ON, as an OH criterion is defined as: normal optic nerve head and retinal nerve fiber layer according to ophthalmoscopy or stereophotography.
• Central corneal thickness (CCT) should be evaluated in every patient with OH.
• Available evidence is not enough to support recommending a specific algorhythm for correcting IOP according to CCT values.
• Selective visual function examination (FDT and SWAP) is recommended for complementary evaluation of patients with OH.
• Imaging examination of structure (GDxVCC, HRT, OCT) is recommended for complementary evaluation of patients with OH.
• There is no precise IOP limit beyond which every patient with OH should be treated.
• A patient with OH should be treated when the analysis of the risk factors involved indicates moderate/high risk of conversion to glaucoma.
• There is no evidence supporting that abnormality of imaging studies (GDxVCC, HRT, OCT) is reason enough to begin treatment in OH.
• Topical hypotensive medication should be the first step of OH treatment.
• A consensus could not be reached on the following topics: a) whether available evidence supports that the presence of reproducible FDT/SWAP abnormality in ocular hypertensive subjects is enough to begin therapy; b) which drug should be used as first-line treatment for OH; and c) whether available evidence is enough to support that therapeutic measures other than reducing IOP may (or may not) be beneficial in OH.

Open angle glaucoma

• The definition of open angle glaucoma must include: a) chronic, progressive, multifactorial anterior optic neuropathy; b) with or without high IOP; and c) an ON of glaucomatous appearance.
• An early glaucomatous appearance of the ON includes ophthalmoscopy or stereophotography showing neuroretinal rim (I.S.N.T. rule) modification or showing loss of RNFL.
• IOP is nowadays the only POAG factor on which we may act in order to reduce the risk of progression of glaucomatous damage.
• Medical therapy is the first step in the treatment of POAG.
• Finding an ON sign compatible with glaucoma on ophthalmoscopy or on stereophotography should be considered an indication for therapy.
• Switching from monotherapy to dual therapy implies the former's failure to reach target IOP.
• In a patient with advanced glaucomatous damage, a target IOP of < 13 mmHg should be considered.