Medical Care

Progression to glaucoma

Start treatment if documentation of progression to glaucoma with optic nerve damage and/or reproducible visual field defect exists. The initiation of ocular hypotensive medication among glaucoma suspects significantly reduced the velocity of VF progression.^[37]

Ocular hypertension

Ocular hypertension with pressure-lowering medication may delay or prevent subsequent development of glaucomatous damage. The OHTS, a large multicenter clinical trial sponsored by the National Eye Institute, studied this possibility. The OHTS concluded that for individuals with ocular hypertension at significant risk for developing glaucoma, topical ocular hypotensive medications were effective in delaying or preventing the onset of primary open-angle glaucoma (POAG).^{[20, 38, 39]}

In general, most ophthalmologists treat patients with IOP of greater than 30 mm Hg.

Glaucoma suspects at high risk

Carefully weigh the likelihood that the patient's risk factors will contribute to glaucomatous optic nerve damage against the ocular and systemic risks that are associated with possible treatments.^[40]Lim et al found that 2.6% of normal-tension glaucoma suspects progressed to glaucoma per year, with higher baseline IOP and thin average retinal nerve fiber layer being risk factors for progression.^[41]

The decision to treat a patient who is glaucoma suspect and at high risk is individualized, considering the following: the risks and the rate at which glaucomatous damage and decreased visual function can occur, the patient's desires, expected longevity, and tolerance of treatment.

Other factors, such as reliability of visual field testing, availability of follow-up visits, and ability to examine the optic disc, may contribute to starting treatment.

If an ophthalmologist decides to treat a patient who is glaucoma suspect and at high risk, using one or more topical antiglaucoma agents to lower the IOP may be preferable.^[42]The adverse effects, the profile, and the frequency of use should be weighed against the patient's ocular and medical histories.

Surgical Care

In patients with very shallow, occludable anterior chamber angle depth, laser peripheral iridotomy can be a preventive measure in decreasing the risk of acute angle-closure glaucoma.

Laser trabeculoplasty is infrequently indicated for treating patients who are glaucoma suspect. In patients with POAG and OHT, the percentage of IOP reduction after SLT was significantly greater in eyes with thinner corneas (CCT < 555 μm), indicating patients with thinner corneas had better IOP control after SLT.^[43]

Filtering procedures are generally reserved for patients with documented glaucomatous optic nerve damage.

Long-Term Monitoring

The frequency and the composition of follow-up evaluation depend on the age of the patient, the level of elevation of IOP, the appearance of optic nerve head cupping, a family history of glaucoma, the presence of additional risk factors, and the stability of the patient's clinical course.

In general and depending on the patient's risk factors, check IOP every 3-12 months. If the patient is a low-tension glaucoma suspect with normal IOP but suspicious optic nerve head cupping, conduct a diurnal assessment of IOP.

Perform visual field examinations every 6-12 months. If a new visual field defect is suspected, the test should be repeated (preferably within 1 mo) to ensure that the defect is reproducible.

Gonioscopy and optic nerve head evaluation are generally performed annually.

Baseline documentation, such as stereo disc photographs, should be obtained for future comparison to objectively evaluate any possible subtle progression. In selected patients, some ophthalmologists prefer to obtain this documentation yearly for detailed comparison.

Questions

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