Medical versus surgical interventions for open angle glaucoma

School of Medicine, Medical and Biological Sciences Building, University of St Andrews, Fife, UK. .
Cochrane database of systematic reviews (Online) (Impact Factor: 5.94). 01/2012; 9(9):CD004399. DOI: 10.1002/14651858.CD004399.pub3
Source: PubMed

ABSTRACT Open angle glaucoma (OAG) is a common cause of blindness.
To assess the effects of medication compared with initial surgery in adults with OAG.
We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 7), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to August 2012), EMBASE (January 1980 to August 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to August 2012), Biosciences Information Service (BIOSIS) (January 1969 to August 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1937 to August 2012), OpenGrey (System for Information on Grey Literature in Europe) (, Zetoc, the metaRegister of Controlled Trials (mRCT) ( and the WHO International Clinical Trials Registry Platform (ICTRP) ( We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 1 August 2012. The National Research Register (NRR) was last searched in 2007 after which the database was archived. We also checked the reference lists of articles and contacted researchers in the field.
We included randomised controlled trials (RCTs) comparing medications with surgery in adults with OAG.
Two authors independently assessed trial quality and extracted data. We contacted study authors for missing information.
Four trials involving 888 participants with previously untreated OAG were included. Surgery was Scheie's procedure in one trial and trabeculectomy in three trials. In three trials, primary medication was usually pilocarpine, in one trial it was a beta-blocker.The most recent trial included participants with on average mild OAG. At five years, the risk of progressive visual field loss, based on a three unit change of a composite visual field score, was not significantly different according to initial medication or initial trabeculectomy (odds ratio (OR) 0.74, 95% confidence interval (CI) 0.54 to 1.01). In an analysis based on mean difference (MD) as a single index of visual field loss, the between treatment group difference in MD was -0.20 decibel (dB) (95% CI -1.31 to 0.91). For a subgroup with more severe glaucoma (MD -10 dB), findings from an exploratory analysis suggest that initial trabeculectomy was associated with marginally less visual field loss at five years than initial medication, (mean difference 0.74 dB (95% CI -0.00 to 1.48). Initial trabeculectomy was associated with lower average intraocular pressure (IOP) (mean difference 2.20 mmHg (95% CI 1.63 to 2.77) but more eye symptoms than medication (P = 0.0053). Beyond five years, visual acuity did not differ according to initial treatment (OR 1.48, 95% CI 0.58 to 3.81).From three trials in more severe OAG, there is some evidence that medication was associated with more progressive visual field loss and 3 to 8 mmHg less IOP lowering than surgery. In the longer-term (two trials) the risk of failure of the randomised treatment was greater with medication than trabeculectomy (OR 3.90, 95% CI 1.60 to 9.53; hazard ratio (HR) 7.27, 95% CI 2.23 to 25.71). Medications and surgery have evolved since these trials were undertaken.In three trials the risk of developing cataract was higher with trabeculectomy (OR 2.69, 95% CI 1.64 to 4.42). Evidence from one trial suggests that, beyond five years, the risk of needing cataract surgery did not differ according to initial treatment policy (OR 0.63, 95% CI 0.15 to 2.62).Methodological weaknesses were identified in all the trials.
Primary surgery lowers IOP more than primary medication but is associated with more eye discomfort. One trial suggests that visual field restriction at five years is not significantly different whether initial treatment is medication or trabeculectomy. There is some evidence from two small trials in more severe OAG, that initial medication (pilocarpine, now rarely used as first line medication) is associated with more glaucoma progression than surgery. Beyond five years, there is no evidence of a difference in the need for cataract surgery according to initial treatment.The clinical and cost-effectiveness of contemporary medication (prostaglandin analogues, alpha2-agonists and topical carbonic anhydrase inhibitors) compared with primary surgery is not known.Further RCTs of current medical treatments compared with surgery are required, particularly for people with severe glaucoma and in black ethnic groups. Outcomes should include those reported by patients. Economic evaluations are required to inform treatment policy.

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    ABSTRACT: Background Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open-angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information, teaching drop instillation technique and ongoing support according to the patient need may have a positive effect on improving adherence. Objectives To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 6), MEDLINE (June 1946 to June 2012), EMBASE (June 1980 to June 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (June 1937 to June 2012), PsycINFO (1806 to June 2012), PsycEXTRA (1908 to June 2012), Web of Science (1970 to June 2012), ZETOC (1993 to June 2012), OpenGrey (System for Information on Grey Literature in Europe) (, the metaRegister of Controlled Trials (mRCT) (, ( and the WHO International Clinical Trials Registry Platform(ICTRP) ( We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 June 2012. We did not search the National Research Register (NNR) as this resource has now been now archived. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO). Selection criteria We included randomised controlled trials (RCTs) and quasi-RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma. Data collection and analysis At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We did not pool data due to clinical and methodological heterogeneity. Main results Sixteen trials (1565 participants) met the inclusion criteria. Seven studies investigated some form of patient education. In six of these studies this education was combined with other behavioural change interventions including tailoring daily routines to promote adherence to eye drops. Eight studies compared different drug regimens (one of these trials also compared open and masked monitoring) and one study investigated a reminder device. The studies were of variable quality and some were at considerable risk of bias; in general, the length of follow-up was short at less than six months with only two studies following up to 12 months. Different interventions and outcomes were reported and so it was not possible to produce an overall estimate of effect. There was some evidence from three studies that education combined with personalised interventions, that is, more complex interventions, improved adherence to ocular hypotensive therapy. There was less information on other outcomes such as persistence and intraocular pressure, and no information on visual field defects, quality of life and cost. There was weak evidence as to whether people on simpler drug regimens were more likely to adhere and persist with their ocular hypotensive therapy. A particular problem was the interpretation of cross-over studies, which in general were not reported correctly. One study investigated a reminder device and monitoring but the study was small and inconclusive. Authors' conclusions Although complex interventions consisting of patient education combined with personalised behavioural change interventions, including tailoring daily routines to promote adherence to eye drops, may improve adherence to glaucoma medication, overall there is insufficient evidence to recommend a particular intervention. The interventions varied between studies and none of the included studies reported on the cost of the intervention. Simplified drug regimens also could be of benefit but again the current published studies do not provide conclusive evidence. Future studies should follow up for at least one year, and could benefit from standardised outcomes.
    Cochrane database of systematic reviews (Online) 04/2013; DOI:10.1002/14651858.CD006132.pub3 · 5.94 Impact Factor
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    ABSTRACT: Glaucoma is the second highest cause of blindness worldwide with an estimated half of the glaucoma population unaware of their disease. To date, intraocular pressure is the most important modifiable risk factor and lowering it has been proven to reduce progression of visual field loss associated with glaucoma. Different strategies are available to lower intraocular pressure and include medical, laser, or surgical treatment in the form of topical or systemic medications, argon or selective laser trabeculoplasty, and glaucoma drainage surgery such as trabeculectomy, deep sclerectomy, or other drainage devices. The effectiveness of these treatments has been well documented however their cost-effectiveness between the developed world and third world remains unclear.
    ClinicoEconomics and Outcomes Research 01/2014; 6:523-30. DOI:10.2147/CEOR.S30697
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    ABSTRACT: Purpose: Specific to individuals with glaucoma: (1) provide an overview of the role of occupational therapists (OTs) as part of the vision rehabilitation team, (2) outline evaluation and intervention approaches provided by OTs, and (3) summarize the evidence to support those intervention approaches. Methods: Literature on vision rehabilitation and the typical practice patterns of OTs working with individuals with glaucoma are reviewed and the occupational therapy process is applied to evaluation and intervention approaches. The evidence which supports intervention approaches for individuals with glaucoma is presented. Results: The strength of the evidence to support common intervention approaches employed by OTs is weak or inconclusive; many studies lack quality methodological rigor. Moderate evidence supports patient education programs and strong evidence supports problem-solving and self-management strategies; this evidence is based on a limited number of studies. Conclusion: The prevalence of eye diseases is increasing; knowledge of how visual impairment affects disability will inform resource allocation and development of rehabilitation programs that address the unique needs of individuals with glaucoma. Rehabilitation specialists are key members of the healthcare team aligned to proactively recognize and develop comprehensive rehabilitation programs to maximize individuals’ function, quality of life and independence in everyday living.Implications for Rehabilitation: Glaucoma is one of the four major eye diseases that may result in visual impairment leading to disability.Research supports intervention approaches and vision rehabilitation techniques used by occupational therapists to optimize the health and well-being of individuals with glaucoma.Rehabilitation specialists are key members of the healthcare team who need to be alert to subtle behaviors that may be indicative of visual impairment versus attributed to other client factors.
    Disability and Rehabilitation 09/2014; DOI:10.3109/09638288.2014.961651 · 1.84 Impact Factor