Should you treat patients with early glaucoma? According to a presentation at the 2021 American Glaucoma Society’s Annual Meeting by Henry Jampel, MD, Professor of Ophthalmology at Johns Hopkins, the answer is probably no.
One of Dr Jampel's arguments for not initiating early treatment is that that the definition for early glaucoma remains vague. “We don’t really know what early glaucoma is,” he said, questioning if it was an elevated IOP alone or if it must include visual field loss.
As researchers work on establishing a definitive definition of early glaucoma, other studies including the Early Manifest Glaucoma Trial (EMGT) and the United Kingdom Glaucoma Treatment Study (UKGTS) have demonstrated that treatment can be delayed without causing harm.
In the EMGT patients with early glaucoma were randomized to treatment or observation. Patients who delayed the start of treatment for 7 years did not have adverse effects. Furthermore, the effectiveness of treatment in patients with glaucoma who were started on treatment early was modest. After 6 years, worsening was seen in 49% of patients in the treated group compared to 63% in the untreated group. Similar results were found in the UKGTS, where at 2 years, 15% of the treated group had worsened compared with 25% of the untreated group. Quality of life was also similar in the treated and untreated groups at 3 years in the EGMT, although cataracts were more common in the treatment group than in the non-treatment group.
In addition to the vague definition and modest treatment effects, Dr Jampel argued that most patients with early glaucoma do not live long enough to lose important vision, noting that in some populations the average time from glaucoma diagnosis until death is 15 years.
Is not treating ethical? Dr Jampel says it is. “The decision to treat should be based upon an analysis of the risks and benefits of treatment, not just the benefits,” he said, but “Any decision, whether to observe or treat the patient with early glaucoma, should involve the patient in the decision-making process.”
In cases where the patient has a very high IOP or the patient is observed getting worse overtime early glaucoma should be treat. Similarly, if the patient wants to be treated, that should be taken into consideration.
Jampel H. Early Glaucoma Should Not Be Treated. Period. Presented at: 2021 AGS Annual Meeting.