Guideline:
Primary open-angle glaucoma suspect
Bibliographic Source(s)
- Glaucoma Panel Preferred Practice Patterns Committee. Primary open-angle glaucoma suspect. San Francisco (CA): American Academy of Ophthalmology (AAO); 2005. 25 p. (Preferred practice pattern). [107 references]
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: American Academy of Ophthalmology Glaucoma Panel. Primary open-angle glaucoma suspect. San Francisco (CA): American Academy of Ophthalmology; 2002 Oct. 26 p.
All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all Preferred Practice Patterns are current each is valid for 5 years from the "approved by" date unless superseded by a revision.
Guideline Category
Diagnosis
Evaluation
Management
Prevention
Treatment
Intended Users
Health Plans
Physicians
Guideline Objective(s)
To preserve visual function and enhance the patient's health and quality of life by detecting glaucomatous optic nerve damage early and by lowering intraocular pressure (IOP) in individuals at high risk for loss of visual function by addressing the following goals of therapy:
- Identify patients at high risk for developing glaucomatous optic nerve damage.
- Establish a baseline for future comparison (e.g. measurements of IOP central corneal thickness visual fields optic disk peripapillary and retinal nerve fiber layer).
- Identify patients at an early stage who develop glaucomatous optic nerve damage (as manifested by typical or progressive optic nerve or nerve fiber layer abnormalities or by glaucomatous visual field loss) and treat them according to the guidelines of the Primary Open-Angle Glaucoma Preferred Practice Pattern.
- Identify a subset of glaucoma suspects who are at particularly high risk for developing glaucomatous optic nerve damage. This includes two groups of individuals:
- Those without glaucomatous optic nerve damage who can reasonably be expected to develop damage because of the presence of one or more clinical findings or risk factors
- Those who may actually have early glaucomatous optic nerve damage but cannot be reliably diagnosed with currently available examination techniques because the findings are not conclusive
- Consider treatment of high-risk individuals to prevent or retard development of glaucomatous optic nerve damage.
- Minimize the side effects of treatment and its impact on the patient's vision general health and quality of life.
- Educate and involve patients in the management of the disease.
Target Population
Adults with normal-appearing open anterior-chamber angles by gonioscopy with one or more of the following clinical findings or risk factors:
- Appearance of the optic disc or retinal nerve fiber layer that is suspicious for glaucomatous damage
- A visual field suspicious for glaucomatous damage
- Consistently elevated intraocular pressure (IOP) associated with normal appearance of the optic disc and retinal nerve fiber layer and with normal visual field test results
- Elevated IOP measurement
- Older age
- Family history of glaucoma
- African or Hispanic/Latino descent
- Thinner central corneal thickness
Interventions and Practices Considered
Diagnosis
- Comprehensive initial/baseline evaluation in addition to and with special attention to those factors that specifically bear upon the diagnosis course and treatment of glaucoma suspect.
- Review of family ocular and systemic history
- Physical examination including measurement of intraocular pressure (IOP) with a Goldmann tonometer an assessment of pupillary function slit-lamp biomicroscopic examination of the anterior segment central corneal thickness measurement gonioscopy evaluation of the optic nerve head and retinal nerve fiber layer evaluation of the fundus and evaluation of the visual field
Management/Treatment
- Periodic follow-up of glaucoma suspects with evaluation of intraocular pressure visual fields appearance of optic nerves and presence of additional risk factors
- Medical treatment of high-risk glaucoma suspects with intraocular pressure-lowering eye drops including:
- Prostaglandin analogs and beta-adrenergic antagonists (most frequently used)
- Alpha2-adrenergic agonists topical and oral carbonic anhydrase inhibitors and parasympathomimetics (less frequently used)
- Laser and filtering surgery (rarely indicated)
- Patient education counseling and referral
Major Outcomes Considered
- Visual function
- Quality of life
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
In the process of revising this document a detailed literature search of MEDLINE was conducted on the subject of primary open-angle glaucoma suspect for the years 1999 to 2004.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Ratings of Strength of Evidence:
- Level I provides strong evidence in support of the statement. The design of the study allowed the issue to be addressed and the study was performed in the population of interest executed in such a manner as to produce accurate and reliable data and analyzed using appropriate statistical methods. The study produced either statistically significant results or showed no difference in results despite a design specified to have high statistical power and/or narrow confidence limits on the parameters of interest.
- Level II provides substantial evidence in support of the statement. Although the study has many of the attributes of one that provides Level I support it lacks one or more of the components of Level I.
- Level III provides a consensus of expert opinion in the absence of evidence that meets Levels I and II.
Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
The results of a literature search on the subject of primary open-angle glaucoma suspect were reviewed by the Glaucoma Panel and used to prepare the recommendations which they rated in two ways. The panel first rated each recommendation according to its importance to the care process. This "importance to the care process" rating represents care that the panel thought would improve the quality of the patient's care in a meaningful way. The panel also rated each recommendation on the strength of the evidence in the available literature to support the recommendation made.
Rating Scheme for the Strength of the Recommendations
Ratings of Importance to the Care Process
Level A most important
Level B moderately important
Level C relevant but not critical
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
These guidelines were reviewed by Council and approved by the Board of Trustees of the American Academy of Ophthalmology (September 2005).
Major Recommendations
Ratings of importance to the care process (A-C) and ratings of strength of evidence (I-III) are defined at the end of the "Major Recommendations" field.
Diagnosis
The comprehensive initial glaucoma suspect evaluation (history and physical examination) includes all components of the comprehensive adult eye evaluation (Practice Patterns Committee "Comprehensive adult medical eye evaluation" 2005) in addition to and with special attention to those factors that specifically bear upon the diagnosis course and treatment of glaucoma suspects. Completion of the evaluation may require more than one visit; the patient may need to return for further evaluation including additional intraocular pressure (IOP) measurements central corneal thickness determination visual field assessment and optic nerve head and nerve fiber layer evaluation and documentation.
History
The comprehensive initial evaluation for a glaucoma suspect includes a review of ocular [A:III] family (Dielemans et al. 1994) [A:II] and systemic history. [A:III] It also includes an assessment of the impact of visual function on daily living and activities; [A:III] review of pertinent records [A:III] with particular reference to the status of the optic nerve visual field and IOP; [A:III] ocular surgery; [A:III] the use of ocular and systemic medications; [A:III] known local or systemic intolerance to ocular or systemic medications; [A:III] and the severity and outcome of glaucoma in family members including history of visual loss from glaucoma (Tielsch et al. 1994; Wolfs et al. 1998). [B:III]
Physical Examination
In completing the elements in the comprehensive adult medical eye evaluation the physical examination specifically focuses on the following eight elements:
Pupil
The pupils are examined for reactivity and an afferent pupillary defect (Kohn Moss & Podos 1979; Brown et al. 1987). [B:II]
Anterior Segment
A slit-lamp biomicroscopic examination of the anterior segment can provide evidence of physical findings associated with narrow angles corneal pathology or a secondary mechanism for elevated IOP such as pseudoexfoliation pigment dispersion iris and angle neovascularization or inflammation (Practice Patterns Committee "Comprehensive adult medical eye evaluation" 2005). [A:III]
Intraocular Pressure
Intraocular pressure is measured in each eye [A:III] preferably using a contact applanation method (typically a Goldmann tonometer) before gonioscopy or dilation of the pupil (Whitacre & Stein 1993). [A:III] Time of day should be recorded because of diurnal variation (Whitacre & Stein 1993). [C:III] The assessment may benefit from determining diurnal IOP fluctuations either on the same day or on different days.
Central Corneal Thickness
Measurement of central corneal thickness (pachymetry) aids the interpretation of IOP measurement results and stratification of patient risk (Gordon et al. 2002; Medeiros et al. 2003; Agudelo Molina & Alvarez 2002). [A:II] Measurement methods include ultrasonic and optical pachymetry.
Gonioscopy
The diagnosis of primary open-angle glaucoma (POAG) suspect requires careful evaluation of the anterior-chamber angle to exclude angle closure or secondary causes of IOP elevation such as angle recession pigment dispersion peripheral anterior synechiae angle neovascularization and trabecular precipitates (Tasman 2004). [A:III]
Optic Nerve Head and Retinal Nerve Fiber Layer
The preferred technique for optic nerve head and retinal nerve fiber layer evaluation involves magnified stereoscopic visualization (as with the slit-lamp biomicroscope) preferably through a dilated pupil. [A:III] Direct ophthalmoscopy is useful in some cases to complement magnified stereoscopic visualization; it is capable of higher magnification and can provide more comprehensive information of optic nerve detail. Red-free illumination may aid in evaluating the retinal nerve fiber layer. Inability to dilate (or the reason not to dilate) the pupil should be documented. [B:III]
Color stereophotography or computer-based image analysis of the optic nerve head and retinal nerve fiber layer are the best currently available methods of documenting optic disc morphology and should be performed (Caprioli Prum & Zeyen 1996; Uchida Brigatti & Caprioli 1996; Anton et al. 1997; Schuman et al. 1995; American Academy of Ophthalmology 1999; Kamal Bunce & Hitchings 2000; Chauhan et al. 2001; Poinoosawmy et al. 2000; Zangwill et al. "The confocal scanning laser" 2004; Zangwill et al. "Racial differences" 2004; Zeyen et al. 2003). [A:II] In the absence of these technologies a nonstereoscopic photograph or a detailed drawing of the optic nerve head should be recorded but these are less desirable alternatives to stereophotography or computer-based imaging (Shaffer et al. 1975). [A:III]
Fundus
Examination of the fundus through a dilated pupil whenever feasible includes a search for other abnormalities that might account for visual field defects if present (e.g. optic nerve pallor tilted disc disc drusen optic nerve pits optic nerve hypoplasia neurological disease macular degeneration and other retinal disease). [A:III]
Visual Field
The preferred technique for evaluating the visual field is automated static threshold perimetry using either white-on-white standard automated perimetry or short-wavelength automated perimetry (SWAP blue-on-yellow). [A:III] Careful manual combined kinetic and static threshold testing is an acceptable alternative when patients cannot perform automated perimetry reliably or if it is not available. [A:III] Causes of visual field loss other than glaucomatous optic neuropathy should be sought and assessed during the history review and physical examination (Anderson 1989). [A:III] A repeat confirmatory examination for field test results that are unreliable or show a possible new glaucomatous defect should be considered. [A:III] It is important to use a consistent examination strategy when visual field testing is repeated. [A:III]
Management
Intraocular pressure is the only risk factor known to be amenable to treatment in glaucoma and glaucoma suspects. The decision to begin treatment to lower IOP in the glaucoma suspect is complex and depends on ocular systemic medical and psychosocial factors. The determination is based on the ophthalmologist's analysis of the examination results and evaluation of the patient and the patient's preferences. The number and severity of risk factors prognosis management plan and likelihood that therapy once started will be long-term should be discussed involving the patient and family in the decision process. [A:III] Whether or not a patient is treated long-term monitoring for the development of glaucoma is essential [A:III]
The patient who is a POAG suspect has a chronic asymptomatic condition that when treated may require frequent use of one or more expensive medications that may cause significant side effects. When treatment is appropriate an effective regimen requires attention to its effect on IOP (potential impact on the condition) and toxicity (the drug-induced side effects) and the degree to which efficacy is reduced by nonadherence due to visual physical social economic or psychologic factors. The ophthalmologist should consider these issues in choosing a regimen of maximal effectiveness and tolerance to achieve the desired therapeutic response for each patient. [A:III]
Target Intraocular Pressure
In managing the glaucoma suspect for whom treatment is indicated the ophthalmologist strives to achieve a stable range of measured IOPs deemed likely to protect against optic nerve damage. The estimated upper limit of that range is considered the "target pressure." The target pressure will vary among patients and in the same patient it may vary during the clinical course. For glaucoma suspects not being treated the target pressure can be viewed as that pressure over which treatment would be recommended (i.e. the threshold for the initiation of treatment).
If therapy is initiated the ophthalmologist assumes that the measured pretreatment pressure range is that which places the optic nerve at risk for damage. The Ocular Hypertension Treatment Study (which limited enrollment to patients with an IOP of 32 mmHg or below) used a target pressure 20% lower than the mean of several baseline IOP measurements and 24 mmHg or below. This seems an appropriate initial goal. [A:I] At present there is no a priori way to determine the pressure below which optic nerve damage will be prevented in any particular patient. The initial target pressure is an estimate and a means toward the ultimate goal of protecting the optic nerve. Current IOP and its relationship to the target IOP should be evaluated at each visit. [A:III]
Failure to achieve and maintain a target pressure should trigger a reassessment of the treatment regimen in light of the potential risks and benefits of additional or alternative treatment. [A:III] In a glaucoma suspect a definite deterioration in optic nerve structure or visual field (i.e. conversion from glaucoma suspect to glaucoma patient) indicates that the target pressure should be reduced [A:I] and the patient managed as described in the Primary Open-Angle Glaucoma Preferred Practice Pattern. [A:III]
Therapeutic Choices
If the decision to begin treatment is made the choice of initial therapy depends on numerous considerations and discussion of treatment with the patient should include appropriate options. [A:III] In most instances topical medications constitute effective initial therapy. The prostaglandin analogs and the beta adrenergic antagonists are the most frequently used eye drops for lowering IOP in patients with glaucoma. Agents less frequently used include alpha2 adrenergic agonists topical and oral carbonic anhydrase inhibitors and parasympathomimetics.
If a drug fails to reduce IOP it should be replaced with an alternate agent until effective medical treatment is established. [A:III] If a single medication is effective in lowering IOP but the target pressure is not reached combination therapy or switching to an alternative therapy may be appropriate.
The ophthalmologist should discuss the benefits and risks of medical treatment with the patient. [B:III] The ophthalmologist should assess the patient who is being treated with IOP-lowering medication for local and systemic side effects toxicity and possible interactions with other medications. [A:III] The ophthalmologist must be prepared to recognize potential life-threatening adverse reactions. [A:III] To reduce systemic absorption patients should be educated about eyelid closure or nasolacrimal occlusion when applying topical medications. [B:II]
At each examination medication dosage and frequency of use should be recorded. [A:III] Adherence to the regimen and the patient's response to recommendations for therapeutic alternatives or diagnostic procedures should be discussed. [A:III]
Laser and filtering surgery are rarely indicated in the treatment of glaucoma suspects.
Follow-up Evaluation
Guidelines for follow-up frequency are specified in Table 2 in the original guideline document. These guidelines represent the consensus of an expert panel in the absence of conclusive scientific evidence in the literature. The interaction between patient and disease is unique for every patient and management for each patient must be individualized with this in mind. [A:III]
History
The following interval history should be elicited during follow-up visits for POAG suspect patients:
- Interval ocular history [A:III]
- Interval systemic medical history and any change of systemic medications [B:III]
- Side effects of ocular medications if patient is being treated (Stamper et al. 1999) [A:III]
- Frequency and time of last IOP-lowering medications and review of medication use if the patient is being treated [B:III]
Physical Examination
The following components of the physical examination should be performed during follow-up visits for POAG suspect patients:
- Visual acuity [A:III]
- Slit-lamp biomicroscopy [A:III]
- IOP and time of day of measurement [A:III]
Optic nerve head evaluation and documentation (Caprioli Prum & Zeyen 1996; Shaffer et al. 1975; Lichter 1976; Airaksinen Tuulonen & Alanko 1992) and visual field evaluation (Smith Katz & Quigley 1996; Katz et al. 1995; Heijl & Asman 1989) should be performed at least at the recommended intervals listed in Table 2 of the original guideline document. Gonioscopy is indicated when there is a suspicion of an angle-closure component anterior-chamber shallowing anterior-chamber angle abnormalities or if there is an unexplained change in IOP. [A:III] Gonioscopy should be performed periodically (i.e. 1 to 5 years). [A:III]
Adjustment of Therapy
The indications for adjusting therapy are as follows: [A:III]
- Target IOP is not achieved.
- IOP is consistently below target or visual field and optic discs remain stable for years. In this situation a carefully monitored attempt to reduce the medical regimen is appropriate.
- Patient is intolerant of the prescribed medical regimen.
- Patient does not adhere to the prescribed medical regimen.
- Contraindications to individual medicines develop.
Conversion from POAG Suspect to POAG
Any patient who shows evidence of optic nerve deterioration based on optic nerve head appearance increased optic disc cupping retinal nerve fiber layer loss or visual field changes consistent with glaucomatous damage should be diagnosed as having developed POAG and treated as described in the Primary Open-Angle Glaucoma Preferred Practice Pattern (Glaucoma Panel Preferred Practice Patterns Committee "Primary open-angle glaucoma" 2005). [A:III]
Provider and Setting
The performance of certain diagnostic procedures (e.g. tonometry pachymetry perimetry fundus imaging and photography) may be delegated to appropriately trained and supervised personnel. However the interpretations of results and the medical and surgical management of disease require the medical training clinical judgment and the experience of an ophthalmologist.
Counseling/Referral
- Patients should be educated about the disease process the rationale and goals of intervention the status of their condition and the relative benefits and risks of alternative interventions so that they can participate meaningfully in developing an appropriate plan of action. [A:III]
- Patients should be encouraged to alert their ophthalmologists to physical or emotional changes that occur when taking glaucoma medications if prescribed. [A:III] The ophthalmologist should be sensitive to these problems and provide support and encouragement.
Definitions:
Ratings of Importance to Care Process:
Level A most important
Level B moderately important
Level C relevant but not critical
Ratings of Strength of Evidence:
- Level I provides strong evidence in support of the statement. The design of the study allowed the issue to be addressed and the study was performed in the population of interest executed in such a manner as to produce accurate and reliable data and analyzed using appropriate statistical methods. The study produced either statistically significant results or showed no difference in results despite a design specified to have high statistical power and/or narrow confidence limits on the parameters of interest.
- Level II provides substantial evidence in support of the statement. Although the study has many of the attributes of one that provides Level I support it lacks one or more of the components of Level I.
- Level III provides a consensus of expert opinion in the absence of evidence that meets Levels I and II.
Clinical Algorithm(s)
A clinical algorithm for the management of patients with primary open-angle glaucoma suspect (POAG) is provided in the original guideline document.
References Supporting the Recommendations
- Agudelo LM Molina CA Alvarez DL. Changes in intraocular pressure after laser in situ keratomileusis for myopia hyperopia and astigmatism. J Refract Surg 2002 Jul-Aug;18(4):472-4. PubMed
- Airaksinen PJ Tuulonen A Alanko HI. Rate and pattern of neuroretinal rim area decrease in ocular hypertension and glaucoma. Arch Ophthalmol 1992 Feb;110(2):206-10. PubMed
- American Academy of Ophthalmology. Optic nerve head and retinal nerve fiber layer analysis. American Academy of Ophthalmology. Ophthalmology 1999 Jul;106(7):1414-24. PubMed
- Anderson DR. Glaucoma: the damage caused by pressure. XLVI Edward Jackson memorial lecture. Am J Ophthalmol 1989 Nov 15;108(5):485-95. [69 references] PubMed
- Anton A Zangwill L Emdadi A Weinreb RN. Nerve fiber layer measurements with scanning laser polarimetry in ocular hypertension. Arch Ophthalmol 1997;115(3):331-4. PubMed
- Brown RH Zilis JD Lynch MG Sanborn GE. The afferent pupillary defect in asymmetric glaucoma. Arch Ophthalmol 1987 Nov;105(11):1540-3. PubMed
- Caprioli J Prum B Zeyen T. Comparison of methods to evaluate the optic nerve head and nerve fiber layer for glaucomatous change. Am J Ophthalmol 1996 Jun;121(6):659-67. PubMed
- Chauhan BC McCormick TA Nicolela MT LeBlanc RP. Optic disc and visual field changes in a prospective longitudinal study of patients with glaucoma: comparison of scanning laser tomography with conventional perimetry and optic disc photography. Arch Ophthalmol 2001 Oct;119(10):1492-9. PubMed
- Dielemans I Vingerling JR Wolfs RC Hofman A Grobbee DE de Jong PT. The prevalence of primary open-angle glaucoma in a population-based study in The Netherlands. The Rotterdam Study. Ophthalmology 1994 Nov;101(11):1851-5. PubMed
- Glaucoma Panel Preferred Practice Patterns Committee. Primary open-angle glaucoma. San Francisco (CA): American Academy of Ophthalmology (AAO); 2005. 36 p. (Preferred practice pattern). [232 references]
- Gordon MO Beiser JA Brandt JD Heuer DK Higginbotham EJ Johnson CA Keltner JL Miller JP Parrish RK 2nd Wilson MR Kass MA. The Ocular Hypertension Treatment Study: baseline factors that predict the onset of primary open-angle glaucoma. Arch Ophthalmol 2002 Jun;120(6):714-20; discussion 829-30. PubMed
- Heijl A Asman P. A clinical study of perimetric probability maps. Arch Ophthalmol 1989 Feb;107(2):199-203. PubMed
- Kamal DS Bunce C Hitchings RA. Use of the GDx to detect differences in retinal nerve fibre layer thickness between normal ocular hypertensive and early glaucomatous eyes. Eye 2000 Jun;14(Pt 3A):367-70. PubMed
- Katz J Tielsch JM Quigley HA Sommer A. Automated perimetry detects visual field loss before manual Goldmann perimetry. Ophthalmology 1995 Jan;102(1):21-6. PubMed
- Kohn AN Moss AP Podos SM. Relative afferent pupillary defects in glaucoma without characteristic field loss. Arch Ophthalmol 1979 Feb;97(2):294-6. PubMed
- Lichter PR. Variability of expert observers in evaluating the optic disc. Trans Am Ophthalmol Soc 1976;74:532-72. PubMed
- Medeiros FA Sample PA Zangwill LM Bowd C Aihara M Weinreb RN. Corneal thickness as a risk factor for visual field loss in patients with preperimetric glaucomatous optic neuropathy. Am J Ophthalmol 2003 Nov;136(5):805-13. PubMed
- Poinoosawmy D Tan JC Bunce C Membrey LW Hitchings RA. Longitudinal nerve fibre layer thickness change in normal-pressure glaucoma. Graefes Arch Clin Exp Ophthalmol 2000 Dec;238(12):965-9. PubMed
- Preferred Practice Patterns Committee. Comprehensive adult medical eye evaluation. San Francisco (CA): American Academy of Ophthalmology (AAO); 2005. 15 p. (Preferred practice pattern). [76 references]
- Schuman JS Hee MR Puliafito CA Wong C Pedut-Kloizman T Lin CP Hertzmark E Izatt JA Swanson EA Fujimoto JG. Quantification of nerve fiber layer thickness in normal and glaucomatous eyes using optical coherence tomography. Arch Ophthalmol 1995 May;113(5):586-96. PubMed
- Shaffer RN Ridgway WL Brown R Kramer SG. The use of diagrams to record changes in glaucomatous disks. Am J Ophthalmol 1975 Sep;80(3 Pt 1):460-4. PubMed
- Smith SD Katz J Quigley HA. Analysis of progressive change in automated visual fields in glaucoma. Invest Ophthalmol Vis Sci 1996 Jun;37(7):1419-28. PubMed
- Stamper R Lieberman MF Drake MV. Becker-Shaffer's diagnosis and therapy of the glaucomas. 7th ed. St. Louis (MO): CV Mosby Co.; 1999.
- Tasman WJ editor(s). Duane's clinical ophthalmology. Philadelphia (PA): JB Lippincott Co.; 2004.
- Tielsch JM Katz J Sommer A Quigley HA Javitt JC. Family history and risk of primary open angle glaucoma. The Baltimore Eye Survey. Arch Ophthalmol 1994 Jan;112(1):69-73. PubMed
- Uchida H Brigatti L Caprioli J. Detection of structural damage from glaucoma with confocal laser image analysis. Invest Ophthalmol Vis Sci 1996 Nov;37(12):2393-401. PubMed
- Whitacre MM Stein R. Sources of error with use of Goldmann-type tonometers. Surv Ophthalmol 1993 Jul-Aug;38(1):1-30. [112 references] PubMed
- Wolfs RC Klaver CC Ramrattan RS van Duijn CM Hofman A de Jong PT. Genetic risk of primary open-angle glaucoma. Population-based familial aggregation study. Arch Ophthalmol 1998 Dec;116(12):1640-5. PubMed
- Zangwill LM Weinreb RN Berry CC Smith AR Dirkes KA Coleman AL Piltz-Seymour JR Liebmann JM Cioffi GA Trick G Brandt JD Gordon MO Kass MA. Racial differences in optic disc topography: baseline results from the confocal scanning laser ophthalmoscopy ancillary study to the ocular hypertension treatment study. Arch Ophthalmol 2004 Jan;122(1):22-8. PubMed
- Zangwill LM Weinreb RN Berry CC Smith AR Dirkes KA Liebmann JM Brandt JD Trick G Cioffi GA Coleman AL Piltz-Seymour JR Gordon MO Kass MA. The confocal scanning laser ophthalmoscopy ancillary study to the ocular hypertension treatment study: study design and baseline factors. Am J Ophthalmol 2004 Feb;137(2):219-27. PubMed
- Zeyen T Miglior S Pfeiffer N Cunha-Vaz J Adamsons I. Reproducibility of evaluation of optic disc change for glaucoma with stereo optic disc photographs. Ophthalmology 2003 Feb;110(2):340-4. PubMed
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified and graded for most recommendations (see "Major Recommendations" field).
Potential Benefits
Loss of vision from glaucoma may be retarded or prevented through early diagnosis and therapy.
Potential Harms
- Patients should be educated about eyelid closure and nasolacrimal occlusion when applying topical medications to reduce systemic absorption.
- Local and systemic side effects toxicity and possible interactions with other medications may occur in patients being treated with intraocular pressure (IOP)-lowering medication.
Qualifying Statements
- Preferred Practice Patterns provide guidance for the pattern of practice not for the care of a particular individual. While they should generally meet the needs of most patients they cannot possibly best meet the needs of all patients. Adherence to these Preferred Practice Patterns will certainly not ensure a successful outcome in every situation. These guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonable directed at obtaining the best results. It may be necessary to approach different patients' needs in different ways. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice.
- Preferred Practice Patterns are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind from negligence or otherwise for any and all claims that may arise out of the use of any recommendations or other information contained herein.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Clinical Algorithm
Personal Digital Assistant (PDA) Downloads
Quick Reference Guides/Physician Guides
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- Glaucoma Panel Preferred Practice Patterns Committee. Primary open-angle glaucoma suspect. San Francisco (CA): American Academy of Ophthalmology (AAO); 2005. 25 p. (Preferred practice pattern). [107 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American Academy of Ophthalmology (AAO)
Guideline Committee
Glaucoma Panel; Preferred Practice Patterns Committee
Composition of Group that Authored the Guideline
Glaucoma Panel Members: Douglas E. Gaasterland MD (Chair); R. Rand Allingham MD; Ronald L. Gross MD; Henry D. Jampel MD American Glaucoma Society Representative; Young H. Kwon MD PhD; Bruce E. Prum Jr. MD; Mae O. Gordon PhD Methodologist
Preferred Practice Patterns Committee Members: Sid Mandelbaum MD (Chair); Emily Y. Chew MD; Linda M. Christmann MD; Douglas E. Gaasterland MD; Samuel Masket MD; Stephen D. McLeod MD; Christopher J. Rapuano MD; Donald S. Fong MD MPH Methodologist
Academy Staff: Flora C. Lum MD; Nancy Collins RN MPH; Doris Mizuiri
Financial Disclosures/Conflicts of Interest
The following authors have received compensation within the past 3 years up to and including August 2005 for consulting services regarding the equipment process or product presented or competing equipment process or product presented:
Douglas E. Gaasterland MD: IRIDEX -- Retainer.
Ronald L. Gross MD: Alcon Allergan Ista Merck Pfizer -- Contract payments for research performed. Ad hoc consulting fees and reimbursement of travel expenses. Reimbursement of travel expenses for presentation at meetings or courses.
Henry D. Jampel MD: Alcon Pfizer -- Contribution to research or research funds. Allergan -- Financial interest in a company or companies supplying the equipment process or product presented. Pfizer -- Reimbursement of travel expenses for presentation at meetings or courses.
Bruce E. Prum Jr. MD: Alcon -- Ad hoc consulting fees and reimbursement of travel expenses. Pfizer -- Contribution to research or research funds.
Other authors have no financial interest in the equipment process or product presented or competing equipment process or product presented.
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: American Academy of Ophthalmology Glaucoma Panel. Primary open-angle glaucoma suspect. San Francisco (CA): American Academy of Ophthalmology; 2002 Oct. 26 p.
All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all Preferred Practice Patterns are current each is valid for 5 years from the "approved by" date unless superseded by a revision.
Guideline Availability
Electronic copies: Available from the American Academy of Ophthalmology (AAO) Web site.
Print copies: Available from American Academy of Ophthalmology P.O. Box 7424 San Francisco CA 94120-7424; telephone (415) 561-8540.
Availability of Companion Documents
The following is available:
- Summary benchmarks for preferred practice patterns. San Francisco (CA): American Academy of Ophthalmology; 2006 Nov. 21 p.
Available in Portable Document Format (PDF) from the American Academy of Ophthalmology (AAO) Web site.
Print copies: Available from American Academy of Ophthalmology P.O. Box 7424 San Francisco CA 94120-7424; telephone (415) 561-8540.
Patient Resources
None available
NGC STATUS
This summary was completed by ECRI on November 20 2000. The information was verified by the guideline developer on December 20 2000. This summary was updated on March 12 2003. The updated information was verified by the guideline developer on April 2 2003. This NGC summary was updated by ECRI on January 6 2006. The updated information was verified by the guideline developer on February 9 2006.
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