Appropriateness of Treating Glaucoma Suspects RAND Study Group. For which glaucoma suspects is it appropriate to initiate treatment?

Decision Factors for Glaucoma Suspects and Ocular Hypertensive Treatment at an Academic Center

Aims and background

Practice guidelines assert that high-risk glaucoma suspects should be treated. Yet, there is ambiguity regarding what constitutes a high enough risk for treatment. The purpose of this study was to determine which factors contribute to the decision to treat glaucoma suspects and ocular hypertensive patients in an academic ophthalmology practice.

Materials and methods

Retrospective cohort study of glaucoma suspects or ocular hypertensives at an academic ophthalmology practice from 2014 to 2020. Demographics, comorbidities, intraocular pressure (IOP), optical coherence tomography (OCT) findings, and visual field measurements were compared between treated and untreated patients. A multivariable logistic regression model assessed predictors of glaucoma suspected treatment.

Results

Of the 388 patients included, 311 (80%) were untreated, and 77 (20%) were treated. There was no statistical difference in age, race/ethnicity, family history of glaucoma, central corneal thickness (CCT), or any visual field parameters between the two groups. Treated glaucoma suspects had higher IOP, thinner retinal nerve fiber layers (RNFL), more RNFL asymmetry, thinner ganglion cell-inner plexiform layers (GCIPL), and a higher prevalence of optic disc drusen, disc hemorrhage, ocular trauma, and proliferative diabetic retinopathy (PDR) (p < 0.05 for all). In the multivariable model, elevated IOP {odds ratio [OR] 1.16 [95% confidence interval (CI) 1.04-1.30], p = 0.008}, yellow temporal [5.76 (1.80-18.40), p = 0.003] and superior [3.18 (1.01-10.0), p = 0.05] RNFL quadrants, and a history of optic disc drusen [8.77 (1.96-39.34), p = 0.005] were significant predictors of glaucoma suspect treatment.

Conclusion

Higher IOP, RNFL thinning, and optic disc drusen were the strongest factors in the decision to treat a glaucoma suspect or ocular hypertensive patient. RNFL asymmetry, GCIPL thinning, and ocular comorbidities may also factor into treatment decisions.

Clinical significance

Understanding the clinical characteristics that prompt glaucoma suspect treatment helps further define glaucoma suspect disease status and inform when treatment should be initiated.

How to cite this article

Ciociola EC, Anderson A, Jiang H, et al. Decision Factors for Glaucoma Suspects and Ocular Hypertensive Treatment at an Academic Center. J Curr Glaucoma Pract 2023;17(3):157-165.

Correlation between retinal nerve fiber layer thickness and IOP variation in glaucoma suspects and patients with primary open-angle glaucoma

PURPOSE

To analyze the relationship between retinal nerve fiber layer thickness (RNFLT) and intraocular pressure (IOP) variation in glaucoma suspects (GS) and patients with primary open-angle glaucoma (POAG).

METHODS

Thirty-one GS and 34 POAG patients underwent ophthalmologic examination and 24-h IOP measurements. GS had IOPs ranging from 19 to 24 mmHg and/or suspicious appearance of the optic nerve. POAG patients had reproducible abnormal visual fields. We only included patients who presented with short-term IOP fluctuation >6 mm Hg (∆IOP). Only one eye per patient was included through a randomized process. Peripapillary RNFLT was assessed by spectral-domain optical coherence tomography. We correlated RNFLT with IOP parameters.

RESULTS

Mean IOP was similar between GS and POAG groups (15.6 ± 3.47 vs 15.6 ± 2.83 mmHg, p = 0.90) as was IOP peak at 6 AM (21.7 ± 3.85 vs 21.3 ± 3.80 mmHg, p = 0.68). Statistically significant negative correlations were found in POAG group between IOP at 6 AM and RNFLT in global (r_s = -0.543; p < 0.001), inferior (r_s = -0.540; p < 0.001), superior (r_s = -0.405; p = 0.009), and nasal quadrants (r_s = -0.561; p < 0.001). Negative correlations were also found between ∆IOP and RNFLT in global (r_s = -0.591; p < 0.001), and all other sectors (p < 0.05). In GS IOP at 6 AM correlated only with inferior quadrant (r_s = -0.307; p = 0.047).

CONCLUSION

IOP at 6 AM and ∆IOP had negative correlations with RNFLT quadrants in POAG. In GS this correlation occurred between IOP at 6 AM and inferior quadrant. These findings may indicate potential risk factors for glaucoma progression.

Prospective study of glaucoma referrals across Europe: are we using resources wisely?

BACKGROUND

To investigate the outcomes of glaucoma referrals across different European countries.

METHODS

250 patients newly referred to tertiary referral glaucoma specialist practices in the UK, Hungary, Slovenia, Italy and Greece were prospectively enrolled (50 consecutive patients per centre). Referral accuracy and predictive value of referral criteria for an intervention or further monitoring (positive predictive value) were analysed.

RESULTS

Same-day discharges occurred in 43% (95% CI 39% to 75%) (12/28) of optometrist-initiated referrals (UK only), 37% (95% CI 30% to 45%) (59/158) of ophthalmologist-initiated referrals (all centres) and 54% (95% CI 40% to 68%) (26/48) of self-referrals (Hungary, Italy and Greece). The percentages from all referral sources were 46% (95% CI 32% to 60%) in the UK, 56% (95% CI 44% to 70%) in Hungary, 30% (95% CI 17% to 43%) in Slovenia, 22% (95% CI 11% to 34%) in Italy and 60% (95% CI 46% to 74%) in Greece (p<0.001). Overall, the referring criterion was confirmed in 54% (95% CI 45% to 63%) (64/119) for intraocular pressure (IOP) >21 mm Hg, 56% (95% CI 43% to 69%) (33/59) for a suspicious optic disc and 61% (95% CI 45% to 77%) (22/36) for a suspicious visual field, with large between-country differences (p<0.05 for all comparisons). Of all referrals, 32% (95% CI 26% to 37%) were initiated on the basis of IOP >21 mm Hg only. By combining the IOP criterion with any other referring criterion, the positive predictive value increased from 56% (95% CI 45% to 67%) to at least 89% (95% CI 68% to 100%). In the UK, a hypothetical IOP threshold of >26 mm Hg, as a requirement for IOP-only referrals, would reduce IOP-only referrals by 44%, while not missing any definite glaucoma cases.

CONCLUSION

The accuracy of referrals was poor in the UK and the other countries. Requiring a combination of criteria and raising the IOP threshold for IOP-only referrals are needed to cut waste in clinical care.

Follow-up intervals in patients with Cushing's disease: recommendations from a panel of experienced pituitary clinicians

PURPOSE

Follow-up guidelines are needed to assess quality of care and to ensure best long-term outcomes for patients with Cushing's disease (CD). The purpose of this study was to assess agreement by experts on recommended follow-up intervals for CD patients at different phases in their treatment course.

METHODS

The RAND/UCLA modified Delphi process was used to assess expert consensus. Eleven clinicians who regularly manage CD patients rated 79 hypothetical patient scenarios before and after ("second round") an in-person panel discussion to clarify definitions. Scenarios described CD patients at various time points after treatment. For each scenario, panelists recommended follow-up intervals in weeks. Panel consensus was assigned as follows: "agreement" if no more than two responses were outside a 2 week window around the median response; "disagreement" if more than two responses were outside a 2 week window around the median response. Recommendations were developed based on second round results.

RESULTS

Panel agreement was 65.9% before and 88.6% after the in-person discussion. The panel recommended follow-up within 8 weeks for patients in remission on glucocorticoid replacement and within 1 year of surgery; within 4 weeks for patients with uncontrolled persistent or recurrent disease; within 8-24 weeks in post-radiotherapy patients controlled on medical therapy; and within 24 weeks in asymptomatic patients with stable plasma ACTH concentrations after bilateral adrenalectomy.

CONCLUSIONS

With a high level of consensus using the Delphi process, panelists recommended regular follow-up in most patient scenarios for this chronic condition. These recommendations may be useful for assessment of CD care both in research and clinical practice.

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.

The impact of physician subspecialty training, risk calculation, and patient age on treatment recommendations in ocular hypertension

PURPOSE

To determine whether glaucoma subspecialty training, formal risk estimation, or patient age has an impact on physician treatment recommendations in cases of ocular hypertension.

DESIGN

Experimental study.

METHODS

Members of the American Academy of Ophthalmology (118) and American Glaucoma Society (58) were recruited. Each physician was first asked how many young and old patients with ocular hypertension he or she would treat to prevent someone from progressing to glaucoma (number needed to treat). The physicians then reviewed 100 simulated cases of patients with ocular hypertension and reported their likelihood to treat each case. Half of these cases were presented with an estimated risk of conversion to glaucoma within 5 years and half were presented without an estimate. The treatment recommendations were analyzed to determine whether subspecialty status or the presence of a risk calculation had any impact on treatment recommendations.

RESULTS

Both glaucoma specialists and non-glaucoma specialists were more likely to recommend treatment in cases for which a risk calculation was provided (P = .001). Furthermore, non-glaucoma specialists were more likely to recommend treatment for ocular hypertensive patients than were glaucoma specialists (P < .001). Finally, both groups indicated they were more likely to treat young patients than old.

CONCLUSIONS

Both provision of a risk estimate and lack of glaucoma subspecialty training were associated with physicians being more likely to treat ocular hypertension. These findings have implications with regard to ways in which the treatment of ocular hypertensive patients could be modified and possibly made more consistent with available evidence.

Glaucoma public service announcements: factors associated with follow-up of participants with risk factors for glaucoma

PURPOSE

To determine the prevalence of follow-up and factors associated with completing an eye examination after a glaucoma public service announcement.

DESIGN

Cross-sectional observational study.

PARTICIPANTS

Individuals who participated in the Glaucoma EyeCare Program by calling a toll-free telephone number and receiving referral by meeting inclusion criteria.

METHODS

The Glaucoma EyeCare Program uses public service announcements to encourage those at increased risk for glaucoma to obtain an eye examination. The program requires interested persons to dial a toll-free telephone number to collect demographic, medical, and socioeconomic information, and refers those at higher risk of glaucoma to an ophthalmologist for a free eye examination. The ophthalmologist completes an outcome form, which indicates whether the participant obtained an eye examination and the results of this eye examination. We determined the factors associated with obtaining an eye examination.

MAIN OUTCOME MEASURES

Sociodemographic characteristics associated with obtaining an eye examination after referral through the Glaucoma EyeCare Program.

RESULTS

Ophthalmologists returned outcome forms for 1514 of 6343 participants (24%). Of those with outcome forms, 671 (44.3%) had an eye examination, 756 (49.9%) did not make an appointment, and 87 (5.7%) made an appointment but did not complete the examination. A multivariate logistic regression model showed younger age, female gender, lack of health insurance, medical history of diabetes, and shorter distance to be associated with obtaining an eye examination.

CONCLUSIONS

Public service announcements encourage participants to have an eye examination. Multiple factors alter the success of obtaining an eye examination. Future studies are needed regarding the best method of decreasing the risk of undiagnosed glaucoma.

Glaucoma: genes, phenotypes, and new directions for therapy

Glaucoma, a leading cause of blindness worldwide, is characterized by progressive optic nerve damage, usually associated with intraocular pressure. Although the clinical progression of the disease is well defined, the molecular events responsible for glaucoma are currently poorly understood and current therapeutic strategies are not curative. This review summarizes the human genetics and genomic approaches that have shed light on the complex inheritance of glaucoma genes and the potential for gene-based and cellular therapies that this research makes possible.

[Appropriateness of treating glaucoma suspects. Concordancy study with the RAND study group]

OBJECTIVE

The Appropriateness of Treating Glaucoma Suspects Study Group proposes to identify which patients suspected of glaucoma are suitable for treatment. Our objective is to analyse the concordance between our clinical decisions and this Study Group.

METHODS

Retrospective study of 77 patients (39 suspects, 38 ocular hypertensives). Variables such as age, family history, intraocular pressure, disc size, cup-to-disc ratio, central corneal thickness and life expectancy were collected.They were scored following the Appropriateness of Treating Glaucoma Suspects Scale. Whether there was a consensus to treat or not depended on this value. The kappa index was used to measured the concordancy.

RESULTS

The kappa index was 0.082 (95% confidence interval between -0.11 and 0.27). Total concordancy was obtained in 41 patients (63,08%). We decided to treat 25 patients (22 of which were not treated by the experts) and not to treat 40 patients (2 of which were treated by the experts). In 12 patients there was noconsensus by the experts to treat, but we decided to treat 8 of them.

CONCLUSIONS

[corrected] The concordancy index was low. Others variables such as visual fields and Heidelberg Retina Tomography (HRT III) parameters were not collected by the experts but were important in our decisions. There are no clinical guidelines on suspects. Individualised decisions are still necessary.