Treating patients presenting with advanced glaucoma--should we reconsider current practice?

Abstract

The management of patients presenting with advanced glaucoma presents a challenge to glaucoma clinicians. Presentation with advanced visual field loss is an important risk factor for progression to blindness in the affected eye(s) during the patients' lifetime. Maximising intraocular pressure (IOP) control in such situations is likely to minimise the risk of further visual field deterioration thus either preventing or slowing progression to blindness. Currently most patients presenting with advanced disease in the UK are managed on an escalating regime of medical treatment. Should this fail glaucoma surgery is usually employed to further lower IOP. Although glaucoma surgery is generally a safe and successful intervention it carries a small risk of severe visual loss and is considered by many clinicians as an intervention only to be used following failure of medical treatment. Recently however the National Institute for Clinical Excellence has suggested in its clinical guidelines for management of ocular hypertension and glaucoma that primary surgery should be offered to patients presenting with advanced glaucomatous visual field loss. This is contrary to the practice of most UK ophthalmologists. In this review the current available evidence underlying the management of presentation with advanced disease is examined.

Outcomes of viscocanalostomy and phaco-viscocanalostomy in patients with advanced glaucoma

“…Stead and King’s [7] results for trabeculectomy augmented with MMC in advanced glaucoma fare better in terms of IOP control compared to our group. However, with regard to post-operative interventions, 79.8% patients had some form of bleb manipulation [7] compared to only 8.1% in our study that had Yag GP.…”

“…Fifteen percent had lost > 1 Snellen line at 1 year and 6% had lost > 2 Snellen lines by 2 years post-trabeculectomy (13% with advanced visual field loss). Twenty-seven percent of patients in Stead and King’s study experienced a loss of two or more lines of Snellen acuity [7]. Nine patients (6.7%) in our study experienced a loss of > 2 Snellen lines.…”

“…More recent data suggest this to be in the order of 30% [15]. King et al [7] reported a 63% incidence of cataract requiring surgery in 27% cases. In comparison, only 5% patients in our group required cataract surgery in the study period.…”

“…Stead and King recommend this to be trabeculectomy augmented with MMC [7]. The use of antimetabolites is a recognised risk factor for bleb-related infection and endophthalmitis [22] and reflects the opinion of UK Consultants’ for not advocating primary surgery for this group [2].…”

“…Stead and King [7] have reported medium-term results for trabeculectomy combined with mitomycin C (MMC) in patients with advanced glaucoma (MD ≤ 20 dB). Although trabeculectomy was successful at controlling intraocular pressure (IOP) in this group, a quarter of patients experienced a significant reduction in acuity, with the pre-operative MD cited as the only determinant for it.…”