Guideline:
Care of the patient with open angle glaucoma
Bibliographic Source(s)
- American Optometric Association. Care of the patient with open angle glaucoma. 2nd ed. St. Louis (MO): American Optometric Association; 2002 Aug 17. 104 p. [589 references]
Guideline Status
This is the current release of the guideline.
This guideline updates a previously published version: Care of the patient with open angle glaucoma. St. Louis (MO): American Optometric Association; 1995. 90 p.
According to the guideline developer this guideline has been reviewed on a biannual basis and is considered to be current. This review process involves updated literature searches of electronic databases and expert panel review of new evidence that has emerged since the original publication date.
Guideline Category
Diagnosis
Evaluation
Management
Treatment
Intended Users
Health Plans
Optometrists
Guideline Objective(s)
- To identify patients at risk of developing open angle glaucoma
- To accurately diagnose open angle glaucoma
- To improve the quality of care rendered to patients with open angle glaucoma
- To minimize the damaging effects of open angle glaucoma
- To preserve the gains obtained through treatment
- To inform and educate patients and other health care practitioners about the visual complications risk factors treatment options and adverse reactions to treatments associated with open angle glaucoma
Target Population
Patients with suspected or diagnosed open angle glaucoma
Interventions and Practices Considered
Diagnosis/Evaluation
- Patient history
- Ocular examination
- Supplemental testing
Management/Treatment
- Medical (Pharmaceutical)
- Adrenergic antagonists: beta-blockers
- Prostaglandin analogs
- Alpha-2 adrenergic agonist
- Topical carbonic anhydrase inhibitor
- Adrenergic agonists: epinephrine compounds
- Miotics
- Oral carbonic anhydrase inhibitors
- Laser therapy
- Surgery
- Filtering procedures
- Cyclodestructive procedures
- Alternative strategies
- Patient education
Major Outcomes Considered
- Efficacy of treatment
- Adverse effects of treatment/medications
Methods Used to Collect/Select Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
The guideline developer performed literature searches using the National Library of Medicine's Medline database and the VisionNet database.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review
Review of Published Meta-Analyses
Description of the Methods Used to Analyze the Evidence
Not applicable
Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation
The Reference Guide for Clinicians was reviewed by the American Optometric Association (AOA) Clinical Guidelines Coordinating Committee and approved by the AOA Board of Trustees.
Major Recommendations
Initial Glaucoma Evaluation
The initial glaucoma evaluation may include the tests and procedures of a comprehensive adult eye and vision examination in addition to some procedures specific to the differential diagnosis of glaucoma. Baseline data are established for key clinical parameters that must be evaluated longitudinally in the proper management of glaucoma. Potential components of an initial glaucoma evaluation (discussed in detail in the original guideline document) include:
- Patient history
- Ocular and systemic risk factors and medical history
- Visual acuity
- Corrected and uncorrected visual acuity
- Pupil assessment
- Relative afferent pupillary defect
- Biomicroscopy
- Evaluation of anterior and posterior ocular segment
- Applanation tonometry
- Diurnal variability
- Symmetry
- Gonioscopy
- Open or closed angle
- Primary or secondary glaucoma
- Assessment of optic nerve
- Stereoscopic evaluation through a dilated pupil
- Tomography
- Assessment of nerve fiber layer
- Stereoscopic evaluation through a dilated pupil
- Evaluation with red-free illumination
- Confocal scanning laser polarimetry optical coherence tomography confocal scanning laser ophthalmoscopy
- Assessment of peripapillary area (PPA)
- Fundus stereo photography
- Photodocumentation of optic nerve and nerve fiber layer
- Visual Fields
- Standard automated perimetry
- Frequency doubling perimetry
- Short wavelength automated perimetry
Follow-up Glaucoma Evaluation
Individuals with one or more risk factors who have higher probabilities of developing primary open angle glaucoma (POAG) need more frequent evaluation to rule out the presence of the earliest clinical signs of glaucoma. This evaluation should be done at least yearly in the absence of complicating factors but perhaps more often depending on the person's relative risk of developing glaucoma.
Follow-up evaluation of the patient with diagnosed open angle glaucoma (OAG) is similar to the procedure used to make the initial diagnosis of the disease and may include but is not limited to the following assessments (further discussed in the original guideline document):
- Patient history
- Visual acuity
- Blood pressure and pulse
- Biomicroscopy
- Tonometry
- Gonioscopy
- Optic nerve assessment
- Nerve fiber layer assessment
- Fundus photography
- Automated perimetry
- Supplemental testing
Available Treatment Options
Traditionally glaucoma treatment has begun with pharmacological intervention proceeding to laser therapy and surgery when necessary. This approach was designed to maximize the benefit of the treatment while minimizing the risk to the patient. Recently this method has been challenged as less effective than other sequences of therapy. Many glaucoma patients may require all three treatment options. These options should be available because glaucoma is a chronic progressive disease with no known cure.
In the choice of a specific form of treatment or the decision to alter or provide additional therapy the risk or benefit to the patient must be the overriding consideration. All forms of treatment for glaucoma have potential side effects or complications. The possible impact of the treatment socially psychologically financially and from a convenience standpoint must be evaluated.
The following three levels of treatment are described in greater detail in the guideline document:
Medical (Pharmaceutical)
The treatment of open angle glaucoma (OAG) includes the use of orally administered or topical agents that enhance aqueous outflow or reduce aqueous production or both. Pharmacological management of OAG includes:
- Cholinergic agonists – miotics (pilocarpine – solution gel or membrane-bound wafer; carbachol)
- Adrenergic agonists (nonselective [epinephrine dipivefrin]; selective [apraclonidine brimonidine])
- Beta-adrenergic blocking agents (nonselective [carteolol levobunolol metipranolol timolol] selective [betaxolol])
- Carbonic anhydrase inhibitors (systemic –oral [acetazolamide – injection or sustained release dichlorphenamide methazolamide] topical [dorzolamide brinzolamide])
- Prostaglandin analogs (bimatoprost latanoprost travoprost unoprostone isopropyl)
- Combination medications
Laser therapy
The second level of primary open angle glaucoma (POAG) involves the use of systemic medication or laser procedures. As an alternative to drug therapy argon laser trabeculoplasty (ALT) is a common treatment after topical medication for POAG.
Surgery
Surgical intervention the third level of treatment for POAG is required in many moderate or advanced glaucoma patients to lower the intraocular pressure (IOP) into the target range especially in normal tension glaucoma (NTG) or eyes resistant to other forms of therapy.
Filtration surgical procedures create alternative pathways for the outflow of aqueous. Among various filtering procedures used to lower IOP are thermal sclerostomy posterior or anterior lip sclerectomy trephination and trabeculectomy. Cyclodestructive procedures which damage the ciliary body and thereby decrease aqueous production are less commonly used being reserved for the most advanced stages of the disease.
Patient Education
The proper management of glaucoma requires full compliance by the patient. Patient education regarding the benefits and risks of the treatment and proper use of medications is critical to ensure maximum compliance. Continual reinforcement of the seriousness of the disease and the importance of following the therapy regimen is essential.
Prognosis and Follow-Up
Once treatment for glaucoma has been initiated follow-up examinations are required to monitor: stability of the intraocular pressure (IOP) optic nerve (ON) visual field (VF) and peripapillary area (PPA); patient compliance with the therapy; the presence of side effects associated with the treatment; and the effectiveness of patient education. Follow-up also provides an opportunity to reconfirm the diagnosis. Determining whether the disease is progressing may be clinically challenging due to the difficulty in some patients of distinguishing subtle structural or functional changes representing normal fluctuation from changes caused by progressive glaucomatous damage.
The frequency of follow-up evaluations of a glaucoma patient under active treatment depends on the level of intraocular pressure and the stability and severity of the disease. The following table summarizes the frequency and composition of evaluation and management visits for open angle glaucoma.
Frequency and Composition of Evaluation and Management Visits for Open Angle Glaucoma
| Type of Patient | Frequency of Examination | Tonometry | Gonioscopy | Optic Nerve (ON)/Nerve Fiber Layer (NFL) Assessment | Stereoscopic ON NFL and Peripapillary Area (PPA) Documentation Confocal scanning laser imaging (CSLI)** |
Perimetry** | Management Plan |
|---|---|---|---|---|---|---|---|
| New glaucoma patient or new glaucoma suspect | Weekly or biweekly to achieve target pressure | Multiple readings may be necessary to establish baseline | Standard classification and drawing an initial visit | Dilate; optic nerve drawing at initial visit | As part of initial glaucoma evaluation | Repeat to establish baseline | Prepare problem list with treatment plan |
| Glaucoma suspect | 6 to 12 months depending on level of risk | Multiple readings may be necessary to establish baseline | Annual | Dilate every other visit | Every 2 years; CSLI Annual* | Annual | Review |
| Stable - mild stage | 4 to 6 months | Every visit | Annual | Dilate every other visit | Annual | Annual | Review |
| Stable - moderate stage | 2 to 4 months | Every visit | Annual | Dilate every other visit | Annual | 6 to -12 months; depending on prior data | Review |
| Stable - severe stage | 1 to 3 months | Every visit | 6 months | Dilate every other visit | Annual; CSLI?* | 4 to 8 months depending on prior data | Review |
| Unstable - IOP poorly controlled; ON or VF progressing | Weekly or biweekly until stability is established | Every visit | Initial visit and each time other clinical findings warrant a reassessment | Dilate at initial visit and each time other clinical findings warrant reassessment | Annual or each time ON or NFL changes | 4 to 6 weeks or as needed to establish new baselines | Formulate new plan until stable |
| Recently established stability | 1 to 3 months | Every visit; re-establish baseline | Depends on severity of the glaucoma | Dilate every interim visit | Annual or each time ON or NFL changes | Depends on severity of the disease | Review |
*Confocal scanning laser imaging (CSLI) is recommended once annually in glaucoma suspect patients and those with mild to moderate disease who can respond to standard testing. CSLI may be performed up to 2 times per year for patients in whom visual fields or tonometry cannot be assessed or in patients with unstable borderline control and other glaucoma risk factors. CSLI may not be useful for monitoring stable-severe or end-stage disease.
**Threshold automated perimetry is recommended.
Clinical Algorithm(s)
An algorithm is provided for Optometric Management of the Patient with Primary Open Angle Glaucoma.
Type of Evidence supporting the Recommendations
The type of supporting evidence is not specifically stated for each recommendation.
Potential Benefits
The effectiveness of the treatment of primary open angle glaucoma (POAG) depends on the specific modality and varies significantly between studies. The majority of POAG patients with maximally tolerated medical therapy will show progression of the disease within 10 years of initial treatment. This rate of progression can be reduced if the intraocular pressure (IOP) is maintained at about 16 to 17 mm Hg. In only about one-half of cases is glaucoma adequately controlled 5 years after argon laser trabeculoplasty (ALT) no more than one-third after 10 years. Filtration surgery in a previously unoperated eye with POAG has a high initial success rate. Progression of visual field (VF) loss following filtering surgery can be minimized when the IOP is maintained at about 15 mm Hg. Target IOPs for maintaining stability during the treatment of POAG need to be adjusted on an individual basis depending on patient age cumulative risk for progression of the disease and severity of the glaucoma.
Subgroups Most Likely to Benefit
Risk Factors for the Development of Glaucoma
- Age: The prevalence of glaucoma is 4 to 10 times higher in the older age groups than in persons in their forties.
- Race: African Americans develop primary open angle glaucoma earlier do not respond as well to treatment require surgery at a higher rate and have a higher prevalence of blindness from glaucoma than Caucasians.
- Genetic factors: Close relatives of persons with primary open angle glaucoma have a prevalence of the disease 3 to 6 times greater than that of the general public and first-degree relatives have a 3 to 5 times higher incidence of the disease.
- Ocular: Intraocular pressure has a strong and direct relationship with the prevalence and long-term risk for glaucoma.
Potential Harms
Adverse Effects of Medical Treatment (Pharmaceuticals)
| Pharmaceutical agents | Adverse reactions | |
|---|---|---|
| Ocular | Systemic | |
| Pilocarpine | Stinging irritation Ciliary spasms (myopia) Miosis (vision) Pupillary block Retinal detachment |
Headache pain Sweating Vomiting/diarrhea Salivation Bradycardia Arrhythmia Dyspnea |
| Epinephrine1 | Stinging burning Mydriasis Allergic sensitivity Pigment deposits Cystoid macular edema Increased intraocular pressure (IOP) |
Increased blood pressure Increased heart rate Severe headaches Anxiety |
| Alpha-2 agonists | Allergic sensitvity2 Minimal mydriasis2 Lid retraction2 Conjunctival vasoconstriction2 Stinging burning Foreign body sensation Hyperemia Conjunctival follicles |
Gastrointestinal discomfort Taste abnormalities Headache Fatigue/drowsiness Oral dryness |
| Topical beta-blockers | Stinging burning Superficial punctate keratitis Allergic sensitivity Decreased corneal sensitivity Uveitis4 |
Dyspnea3 Bronchiole constriction3 Decreased heart rate3 Arrhythmias3 Decreased blood pressure Depression confusion Gastrointestinal discomfort Impotence Sleep disturbance Serum lipoprotein alterations Masking symptoms of diabetes mellitus and hyperthyroidism |
| Oral carbonic anhydrase inhibitors | None | Malaise Depression confusion Metallic taste Anorexia Diarrhea Paresthesias Kidney stones Metabolic acidosis Blood dyscrasias |
| Topical carbonic anhydrase inhibitors | Stinging/burning Allergic sensitivity Blurred vision Superficial punctate keratitis Corneal edema |
Altered taste |
| Prostaglandin analogs | Blurred vision Stinging burning Hyperemia Foreign body sensation Itching Increased iris pigmentation5 Eyelash changes Punctate epithelial keratitis Cystoid macular edema Iritis Herpes simplex keratitis |
Headaches Upper respiratory tract symptoms |
1 Adverse ocular reactions and contraindications are less with dipivefrin than with epinephrine
2Adverse ocular reactions are less common with brimonidine
3May be less severe with betaxolol
4Metipranolol
5Only one reported change in iris coloration with unoprostone isopropyl
Complications of Laser therapy
Possible complications of argon laser trabeculoplasty (ALT) include an increase in intraocular pressure within hours of the procedure and inflammation which may lead to the formation of peripheral anterior synechiae.
Complications of Surgery
Short-term complications from filtering surgery can include the development of shallow anterior chambers hypotony choroidal detachment uveitis hyphema suprachoroidal hemorrhages and loss of a remaining small island of central vision. Long-term complications can include corneal edema infection leaking or failure from fibrosis of the subconjunctival bleb cataract formation and endophthalmitis.
Contraindications
Contraindications to Pharmaceutical Agents
| Contraindications | ||
|---|---|---|
| Ocular | Systemic | |
| Pilocarpine | History of retinal detachment Severe myopia Cataracts Inflammation/infection Aphakia/pseudophakia |
Asthma Ulcers Bladder dysfunction Parkinson's disease |
| Epinephrine | Aphakia/pseudophakia Narrow angles |
Systemic hypertension Heart disease Hyperthyroidism Diabetes mellitus Certain medications |
| Alpha-2 agonists | None | None |
| Topical beta-blockers | Narrow angles | Chronic obstructive pulmonary disease (COPD) Systemic hypotension Bradycardia Diabetes mellitus Myasthenia gravis Certain medications |
| Oral carbonic anhydrase inhibitors | None | History of kidney stones Liver disease Sulfonamide allergy Cardiac disease Addison's disease Renal disease Severe COPD |
| Topical carbonic anhydrase inhibitors | Corneal endothelium compromise | Sulfonamide allergy |
| Prostaglandin analogs | History of uveitis cystoid macular edema herpes simplex keratitis complicated cataract surgery | None |
Contraindication to Laser Therapy
The use of argon laser trabeculoplasty (ALT) is contraindicated in patients with corneal edema or opacities that prevent a clear view of the anterior chamber angle in those who have certain forms of secondary glaucoma and in situations where a large decrease in intraocular pressure is required.
Contraindications to Surgery
Filtering surgery is contraindicated in eyes that are already blind and in patients with severe systemic medical problems.
Qualifying Statements
- Clinicians should not rely on this Clinical Guideline alone for patient care and management. Please refer to the references and other sources listed in the original guideline for a more detailed analysis and discussion of research and patient care information.
- The components of patient care described in this guideline are not intended to be all-inclusive. Professional judgment and individual patient symptoms and findings may have significant impact on the nature extent and course of services provided. Some components of care may be delegated.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Clinical Algorithm
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- American Optometric Association. Care of the patient with open angle glaucoma. 2nd ed. St. Louis (MO): American Optometric Association; 2002 Aug 17. 104 p. [589 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
Funding was provided by the Vision Service Plan (Rancho Cordova California) and its subsidiary Altair Eyewear (Rancho Cordova California)
Guideline Committee
American Optometric Association Consensus Panel on Care of the Patient with Open Angle Glaucoma
Composition of Group that Authored the Guideline
Members: Thomas L. Lewis OD PhD (Author); Howard S. Barnebey MD (1st Edition); Jimmy D. Bartlett OD; Allen J. Blume OD; Murray Fingeret OD; Peter A. Lalle OD; Daryl F. Mann OD
Assisted by: Sigrid Mueller OD; Kelly S. Shintani OD
AOA Clinical Guidelines Coordinating Committee Members: John C. Townsend OD Chair (2nd Edition); John F. Amos OD MS (1st and 2nd Editions); Barry Barresi OD PhD (1st Edition); Kerry L. Beebe OD (1st Edition); Jerry Cavallerano OD PhD (1st Edition); John Lahr OD (1st Edition); W. Howard McAlister OD MPH (2nd Edition); Stephen C. Miller OD (2nd Edition); David Mills OD (1st Edition)
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
This guideline updates a previously published version: Care of the patient with open angle glaucoma. St. Louis (MO): American Optometric Association; 1995. 90 p.
According to the guideline developer this guideline has been reviewed on a biannual basis and is considered to be current. This review process involves updated literature searches of electronic databases and expert panel review of new evidence that has emerged since the original publication date.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the American Optometric Association Web site.
Print copies: Available from the American Optometric Association 243 N. Lindbergh Blvd. St. Louis MO 63141-7881.
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This summary was completed by ECRI on December 2 1999. The information was verified by the guideline developer as of January 31 2000. This summary was updated by ECRI on April 16 2004. The information was verified by the guideline developer on May 10 2004.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions as follows:
Copyright to the original guideline is owned by the American Optometric Association (AOA). NGC users are free to download a single copy for personal use. Reproduction without permission of the AOA is prohibited. Permission requests should be directed to Jeffrey L. Weaver O.D. Director Clinical Care Group American Optometric Association 243 N. Lindbergh Blvd. St. Louis MO 63141; (314) 991-4100 ext. 244; fax: (314) 991-4101; e-mail: JLWeaver@AOA.org.
NGC Disclaimer
The National Guideline Clearinghouse™ (NGC) does not develop produce approve or endorse the guidelines represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies relevant professional associations public or private organizations other government agencies health care organizations or plans and similar entities.
Guidelines represented on the NGC Web site are submitted by guideline developers and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .
NGC AHRQ and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC AHRQ or its contractor ECRI Institute and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.
Tools
No Quick Reference tools have been developed.