Evidence-based update of the Primary Open-Angle Glaucoma Preferred Practice Pattern® (PPP) guidelines, describing the diagnosis and management of patients with primary open-angle glaucoma with an algorithm for patient management and detailed recommendations for evaluation and treatment options.

Purpose Visual field testing uses high contrast stimuli in areas of severe visual field loss. However, retinal ganglion cells saturate with high contrast stimuli, suggesting that the probability of detecting perimetric stimuli may not increase indefinitely as contrast increases. Driven by this concept, this study examines the lower limit of perimetric sensitivity for reliable testing by standard automated perimetry. Design Evaluation of diagnostic test. Participants 34 participants with moderate to severe glaucoma (Mean Deviation (MD) on their last clinic visit averaged −10.90dB, range −20.94dB to −3.38dB). 75 of the 136 locations tested had perimetric sensitivity ≤19dB. Methods Frequency of seeing curves were constructed at four non-adjacent visual field locations by the method of constant stimuli (MOCS), using 35 stimulus presentations at each of 7 contrasts. Locations were chosen a priori, and included at least two with glaucomatous damage but sensitivity ≥6dB. Cumulative Gaussian curves were fit to the data, first assuming a 5% false negative rate, and subsequently allowing the asymptotic maximum response probability to be a free parameter. Main Outcome Measures The strength of the relation (R2) between perimetric sensitivity (mean of last two clinic visits) and MOCS sensitivity (from the experiment), for all locations with perimetric sensitivity within ±4dB of each selected value, at 0.5dB intervals. Results Bins centered at sensitivities ≥19dB always had R2>0.1. All bins centered at sensitivities ≤15dB had R2<0.1, an indication that sensitivities are unreliable. No consistent conclusions could be drawn between 15–19dB. At 57 of the 81 locations with perimetric sensitivity <19dB, including 49 of the 63 locations ≤15dB, the fitted asymptotic maximum response probability was <80%, consistent with the hypothesis of response saturation. At 29 of these locations the asymptotic maximum was below 50%, and so contrast sensitivity (50% response rate) is undefined. Conclusions Clinical visual field testing may be unreliable when visual field locations have sensitivity below approximately 15–19dB, due to a reduction in the asymptotic maximum response probability. Researchers and clinicians may have difficulty detecting worsening sensitivity in these visual field locations and this difficulty may occur commonly in glaucoma patients with moderate to severe glaucomatous visual field loss.

Purpose To determine the change in intraocular pressure (IOP) after cataract extraction in the Observation Group of the Ocular Hypertension Treatment Study (OHTS). Design Comparative case series Participants Forty-two participants (63 eyes) who underwent cataract surgery in at least one eye during the study and a control group of 743 participants (743 eyes) who did not undergo cataract surgery Methods We defined the “split date” as the study visit date that cataract surgery was reported in the cataract surgery group, and a corresponding date in the control group. Preoperative IOP was defined as the mean IOP of up to 3 visits prior to split date. Postoperative IOP was the mean IOP of up to 3 visits including the split date (0, 6, and 12 months with ‘0 months’ equaling the split date). In both groups, we censored data after initiation of ocular hypotensive medication, or glaucoma surgery of any kind. Main outcome measures Difference in preoperative and postoperative IOP. Results In the cataract group, postoperative IOP was significantly lower than the preoperative IOP (19.8 ± 3.2 mmHg vs. 23.9 ± 3.2 p<0.001). The postoperative IOP remained lower than preoperative IOP for at least 36 months. The average decrease in postoperative IOP from preoperative IOP was 16.5%, and 39.7% of eyes had postoperative IOP ≥ 20% below preoperative IOP. A greater reduction in postoperative IOP occurred in the eyes with the highest preoperative IOP. In the control group, the corresponding mean IOP’s were 23.8 ± 3.6 prior to the split date and 23.4 ± 3.9 after the split date. Conclusion Cataract surgery decreases IOP in ocular hypertensive patients over a long period of time.

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