For Which Glaucoma Suspects Is It Appropriate to Initiate Treatment?

Abstract

Objective Because uncertainty exists about which glaucoma suspects should be treated, we sought to identify glaucoma suspects whom an expert panel could agree would be appropriate or inappropriate to treat. Design RAND/UCLA appropriateness method, a well-established procedure to synthesize the scientific literature with expert opinion to resolve uncertainty on a health topic. Participants Eleven-member panel composed of recognized international leaders in the field of glaucoma. Methods Based on a systematic review of the literature on potentially important factors to consider when deciding to initiate treatment, we initially created over 1000 scenarios of glaucoma suspects. The panel formally rated the appropriateness of initiating treatment for glaucoma suspects through a two-round modified Delphi method, a technique that preserves the confidentiality of individual panelists’ ratings but allows panelists to compare their own ratings to those of the entire panel. Main Outcome Measures Final ratings for scenarios were categorized as appropriate, uncertain, or inappropriate to treat according to typical pre-specified statistical criteria previously used in projects using the RAND/UCLA appropriateness method. Tools were developed to help clinicians approximate the panel ratings of glaucoma suspects. Results The panel chose age, life expectancy, intraocular pressure (IOP), central corneal thickness, cup/disc ratio, disc size, and family history as the variables to consider when deciding whether to treat glaucoma suspects. Permutations of these variables created 1800 unique scenarios. The panel rated 587 (33%) scenarios as appropriate, 585 (33%) as uncertain, and 628 (35%) as inappropriate for treatment initiation. Analysis of variance determined that IOP had greater impact than any other variable on panel ratings. We created a point system with 96% sensitivity and 93% specificity for predicting panel ratings of appropriateness for a glaucoma suspect. Conclusions An expert panel can reach agreement on the appropriateness and inappropriateness of treatment for glaucoma suspects.

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

“…Although glaucoma suspects often develop glaucoma, there is a lack of uniformity regarding when to initiate treatment in these patients. 2 , 7 The OHTS and additional studies found a variety of risk factors for the development of POAG that should be considered when determining how to manage glaucoma suspect patients, including older age, African American race, Hispanic ethnicity, male sex, larger cup-to-disc ratios (CDR), high IOP, family history of glaucoma, higher visual field standard deviation, greater pattern standard deviation (PSD), type 2 diabetes, high myopia, and a thinner central corneal measurement. 4 , 5 , 8 – 12 The American Academy of Ophthalmology's Preferred Practice Pattern on management of glaucoma suspect patients recommends determining if a patient is at high risk for developing glaucomatous optic neuropathy while considering the potential benefits and risks of treatment.…”