Disease progression, irrespective of intraocular pressure, should guide escalation of treatment in glaucoma

The Science behind the Tip

The objective of clinical intervention in patients with glaucoma is to slow down disease progression. Intraocular pressure (IOP) remains, at present, the only modifiable risk factor to influence the course of the disease. However, patients exhibit variable rates of progression even with similar levels of IOP (1, 2). Recent evidence has demonstrated that the visual field (VF) progression can be significantly slower in patients treated with surgery (2, 3) or selective laser trabeculoplasty (1) compared to those treated with drops, possibly due to gaps in dosing and compliance causing fluctuations in IOP. Clinicians often try to capture this aspect by investigating IOP fluctuations with 24-hour or daytime monitoring (phasing). However, phasing curves have been shown to be poorly reproducible (4). Moreover, recent evidence from the United Kingdom Glaucoma Treatment Study showed that IOP fluctuations measurements are poorly correlated with VF progression, after controlling for the average IOP (5). In conclusion, disease progression remains the most important piece of clinical information to guide the management of glaucoma patients. Intensification of treatment, including surgery, must be considered when progression is observed, regardless of the IOP measured in clinic.

References

1. Wright DM, Konstantakopoulou E, Montesano G, et al. Visual Field Outcomes from the Multicenter, Randomized Controlled Laser in Glaucoma and Ocular Hypertension Trial (LiGHT). Ophthalmology 2020;127:1313-1321.
2. Montesano G, Ometto G, Ahmed IIK, et al. Five-Year Visual Field Outcomes of the HORIZON Trial. Am J Ophthalmol 2023;251:143-155.
3. King AJ, Hudson J, Azuara-Blanco A, et al. Evaluating Primary Treatment for People with Advanced Glaucoma: Five-Year Results of the Treatment of Advanced Glaucoma Study. Ophthalmology 2024.
4. Aptel F, Lesoin A, Chiquet C, Aryal-Charles N, Noel C, Romanet JP. Long-term reproducibility of diurnal intraocular pressure patterns in patients with glaucoma. Ophthalmology 2014;121:1998-2003.
5. Rabiolo A, Montesano G, Crabb DP, et al. Relationship between Intraocular Pressure Fluctuation and Visual Field Progression Rates in the United Kingdom Glaucoma Treatment Study. Ophthalmology 2024.

Contributors: Giovanni Montesano, MD, PhD

NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, United Kingdom
Optometry and Visual Sciences, City University of London, London, United Kingdom

Tip of the Month manager: Frances Meier-Gibbons
Tip of the Month editorial board: Francisco Goni, Karl Mercieca, Humma Shahid
Tip of the Month editors in chief: Manuele Michelessi, Francesco Oddone