A panel assessment of glaucoma management: modification of existing RAND-like methodology for consensus in ophthalmology. Part I: Methodology and design

Defining stable glaucoma: a Delphi consensus survey of UK optometrists with a specialist interest in Glaucoma

BACKGROUND

Increasing demand on hospital services has led to the development of alternative community-based services, often run by optometrists for monitoring 'stable' and low-risk glaucoma patients.

METHODS

An online Delphi exercise was undertaken to derive a consensus definition of 'stable glaucoma' amongst optometrists with a special interest in glaucoma. Participants were asked to score their agreement for various clinical parameters. Results from each round were used to inform subsequent rounds.

RESULTS

31 optometrists participated in the study. 100%, 77%, and 68% completion rates were achieved over three rounds respectively. Consensus was reached for 7 parameters: Stability should be defined over a period of 36-48 months, summary measure Visual Field (VF), and/or Trend Analysis should be used to assess VF stability. Two or more decibel (dB) of change of VF mean deviation (MD) is considered unstable. Intraocular pressure (IOP) should be below a target defined by the patient's clinician or a fixed-percentage reduction compared to the presenting IOP. No treatment change during the stability assessment period is considered stable. Imaging with Ocular Coherence Topography Retinal Nerve Fibre Layer (OCT RNFL) assessment should be used to define glaucoma stability. Overview by a glaucoma consultant was considered important for glaucoma monitoring schemes.

CONCLUSION

This Delphi exercise has generated a consensus definition for glaucoma stability by UK Optometrists with a specialist interest in glaucoma. This consensus definition can be used to inform the selection of suitable patients from hospital services for transfer to monitoring in community-based 'stable' optometry run glaucoma clinics.

Seeking a practical definition of stable glaucoma: a Delphi consensus survey of UK glaucoma consultants

BACKGROUND

To generate a practical and clinically useful consensus definition of 'stable glaucoma' to aid provision of glaucoma services in the UK and to provide guidance for the criteria that should be used for monitoring of glaucoma patients in primary care services.

METHODS

A Delphi exercise was undertaken to derive consensus through an online questionnaire. Participants were asked to score their strength of agreement for a series of clinical parameters. Results and comments from each round were used to inform subsequent rounds. A total of 3 rounds were undertaken.

RESULTS

Thirty-two glaucoma experts participated in the study with over 90% completion rate achieved over three rounds. The consensus was reached for the following parameters: IOP levels to be used for defining stability, visual field-testing techniques to define stability, the number of medication changes acceptable to define stability and the number of treatment medications allowed to define stability. No consensus was reached on the period of time over which stability was defined, however, there was considerable agreement that longer durations of follow up (36-48 months) were required. A combination of optic disc photos and ocular coherence topography (OCT) retinal nerve fibre layer (RNFL) assessment/ OCT disc structural evaluation are the preferred imaging methods for the assessment of structural stability. Oversight by a glaucoma consultant was considered important for glaucoma monitoring schemes.

CONCLUSION

The consensus definition of glaucoma stability generated through this Delphi exercise provides guidance for allocation of patients suitable for monitoring in primary care glaucoma monitoring schemes.

Diagnostic ability of macular ganglion cell-inner plexiform layer thickness in glaucoma suspects

The purpose is to assess the diagnostic ability for early glaucoma of macular ganglion cell-inner plexiform layer (GCIPL) thickness in a Chinese population including glaucoma suspects.A total of 367 eyes with primary open-angle glaucoma (168 early glaucoma, 78 moderate glaucoma, and 121 advanced glaucoma), 52 eyes with ocular hypertension (OHT), 59 eyes with enlarged cup-to-disc ratio (C/D), and 225 normal eyes were included. GCIPL thickness (average, minimum, superotemporal, superior, superonasal, inferonasal, inferior, and inferotemporal), retinal nerve fiber layer (RNFL) thickness, and optic nerve head (ONH) parameters were measured using Cirrus high-definition optical coherence tomography (OCT) and compared. The diagnostic ability of OCT parameters was assessed by area under receiver operating characteristic curve (AUROC) in 3 distinguishing groups: normal eyes and eyes with early glaucoma, normal eyes and eyes with glaucoma regardless of disease stage, and nonglaucomatous eyes (normal eyes, eyes with OHT, and enlarged C/D) and early glaucomatous eyes.Glaucomatous eyes showed a significant reduction in GCIPL thickness compared with nonglaucomatous eyes. In all 3 distinguishing groups, best-performing parameters of GCIPL thickness, RNFL thickness, and ONH parameters were minimum GCIPL thickness (expressed in AUROC, 0.899, 0.952, and 0.900, respectively), average RNFL thickness (0.904, 0.953, and 0.892, respectively), and rim area (0.861, 0.925, and 0.824, respectively). There was no statistical significance of AUROC between minimum GCIPL thickness and average RNFL thickness (all P > .05).GCIPL thickness could discriminate early glaucoma from normal and glaucoma suspects with good sensitivity and specificity. The glaucoma diagnostic ability of GCIPL thickness was comparable to that of RNFL thickness.

Over-diagnosis and over-treatment in Ophthalmology: A review of the literature

OBJECTIVE

To determine if the pernicious effects of over-diagnosis and over-treatment have been studied in the most common ocular diseases.

MATERIAL AND METHODS

Bibliographic search conducted in PubMed.

RESULTS

The search algorithm used retrieved 29 articles related with the topic. Most of them address the issue tangentially. Only 4 of them address the problem directly. One of them focuses on the problem of over-diagnosis and over-treatment in idiopathic intracranial hypertension. The remaining 3 focus on the problem of over-diagnosis and over-treatment in glaucoma.

CONCLUSION

The ophthalmology community has thought very little about the detrimental effects of over-diagnosis and over-treatment.

RAND-like appropriateness methodology consensus for primary open-angle glaucoma in Latin America

PURPOSE

To report the results of a Latin American consensus panel regarding the diagnosis and management of primary open-angle glaucoma and to compare these results with those from a similar panel in the United States.

DESIGN

A RAND-like (Research and Development) appropriateness methodology was used to assess glaucoma practice in Latin America.

METHODS

The 148 polling statements created for the RAND- like analysis in the United States and 10 additional statements specific to glaucoma care in Latin America were presented to a panel of Latin American glaucoma experts. Panelists were polled in private using the RAND- like methodology before and after the panel meeting.

RESULTS

Consensus agreement or disagreement among Latin American experts was reached for 51.3% of statements before the meeting and increased to 66.5% in the private, anonymous meeting after polling (79.0% agreement, 21.0% disagreement). Although there was a high degree of concordance (111 of 148 statements; 75%) between the results of this Latin American panel and the United States panel, there were some notable exceptions relating to diagnostic and therapeutic decision making.

CONCLUSIONS

This RAND-like consensus methodology provides a perspective of how Latin American glaucoma practitioners view many aspects of glaucoma and compares these results with those obtained using a similar methodology from practitioners in the United States. These findings may be helpful to ophthalmologists providing glaucoma care in Latin America and in other regions of the world.

Medical management of glaucoma: principles and practice

Glaucoma care is more an art than science. The introduction of several new classes of glaucoma medications and the completion of many large randomized clinical trials have not changed this fact. While we now have better choices when initiating glaucoma therapy relative to our predecessors, the principles of glaucoma therapy have not changed much during this period. Debates continue regarding the utility of concepts such as “the monocular therapeutic trial,” “target intraocular pressure (IOP),” and “maximal medical therapy.” Our tools for detecting and following glaucomatous disease have improved but are not precise enough for us to prospectively predict which patients will do better or worse than others. Much attention has been given to disease stage, rate of progression, and compliance with medications but regular patient follow-up, an area that has received little attention, may be among the most important predictors of patient outcomes.

Assessing the Importance of IOP Variables in Glaucoma Using a Modified Delphi Process

PURPOSE

To assess the degree of consensus among glaucoma experts on the measurement, characterization, and potential implications of intraocular pressure (IOP) and its fluctuation for glaucoma treatment.

METHODS

A multinational panel of 9 glaucoma experts used a modified Delphi process to rate the level of agreement with 72 statements characterizing methods of measuring IOP, the importance of IOP reduction, and clinical implications of changes in IOP over time. After receiving a literature review, panelists rated each statement on a 9-point Likert scale. A panel meeting was held to discuss the ratings followed by a second round of independent ratings. Consensus and nonconsensus regarding the panel's agreement with each statement were determined using a binomially distributed statistical definition.

RESULTS

The panel found consensus in 46% of 81 statements, nonconsensus in 6%, and indeterminate status in 48%. Categories having the highest proportion of statements with consensus were importance of IOP reduction (4/4 statements), importance of long-term IOP fluctuation and reduction (6/9), and impact of medication on short-term and long-term IOP fluctuation (6/10 for each). Indeterminate statements were distributed unevenly with 74% of statements related to IOP measurement rated indeterminate compared with 38% related to the clinical implications of short-term and long-term IOP fluctuation.

CONCLUSIONS

A modified Delphi process was useful in identifying areas of consensus regarding IOP measurement and importance of IOP fluctuation among glaucoma experts. Concurrently, the need for additional investigations assessing the role of IOP changes in glaucoma management is highlighted by the indeterminate and nonconsensus ratings.

A panel assessment of glaucoma management: modification of existing RAND-like methodology for consensus in ophthalmology. Part II: Results and interpretation

PURPOSE

To present the results of a panel consensus assessment of evaluation and therapy relating to primary open-angle glaucoma based on available evidence and expert opinion.

DESIGN

A panel consensus assessment of glaucoma diagnosis and therapy using a modified RAND-like appropriateness methodology.

METHODS

One hundred and forty-eight questions, most of which related to glaucoma therapy, were created by a core nonvoting executive committee based on common clinical questions. An evidence-based review of the literature pertaining to these questions was provided to 10 voting panelists. These panelists, who did not participate in either the creation of the questions or the conduct of the literature review, then were polled using a modified technique derived from existing methodology.

RESULTS

Consensus agreement or disagreement was reached for 55.4% and 74.3% of the polling statements before and after the panel meeting, respectively. This represents a consensus agreement or disagreement on a majority of polling statements both before and after a meeting of all panelists and the two co-chairs of the program. There was an increase in the proportion of statements where consensus agreement was reached after the panel meeting.

CONCLUSIONS

Given the paucity of high-quality evidence relating to many of the issues addressed in this assessment and the variability of practice patterns among ophthalmologists, consensus agreement or disagreement was reached for a high proportion of polling statements.