Canadian Ophthalmological Society

1. Evidence-based Clinical Practice Guidelines for the Management of Glaucoma in the Adult Eye Canadian Ophthalmological Society

2. Glaucoma Therapies

3. Overarching and specific management goals • Preserve visual function. • Maintain or enhance overall health-related QOL. • Slow or halt progression of the disease. • Achieved through a careful process of: • observing and monitoring visual function, • providing patient education and support, • providing medical, laser, and (or) surgical interventionas appropriate, and • observation without treatment in some cases. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.

4. Quality-of-life considerations • Glaucomatous field damage adversely affects the patient’s QOL.1,2 • Patients with glaucoma report: • Difficulties with bright lights and with light and dark adaptation.3 • Worry or concern about the possibility of blindness. • Difficulty with mobility (falls and motor vehicle accidents).1,4 • A negative impact associated with the therapy itself. 1. Noe G, et al. Clin Experiment Ophthalmol 2003;31:482–6. 2. Altangerel U, et al. Curr Opin Ophthalmol 2003;14:100–5. 3. Janz NK, et al. Ophthalmology 2001;108:887–97. 4 .Haymes SA, et al. Invest Ophthalmol Vis Sci 2007;48:1149–55. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.

5. Overall and specific managementgoals in patients with glaucoma Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.

6. Lowering IOP andSetting Target IOP

7. Lowering IOP • IOP lowering is the only clinically established method of treating glaucoma. • The effectiveness of IOP lowering has been established in several well-designed prospective RCTs.1-4 1. AGIS Investigators. Am J Ophthalmol 2000;130:429–40. 2. Collaborative Normal-Tension Glaucoma Study Group.Am J Ophthalmol 1998;126:487–97. 3. Heijl A, et al. Arch Ophthalmol 2002;120:1268–79. 4. Chauhan BC, et al. Arch Ophthalmol 2008;126:1030–6. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.

8. Lowering IOP (cont’d) • Reducing fluctuation in IOP (diurnal and (or) intervisit) may also be a worthwhile objective in select patients, such as those with: • advanced glaucoma, or • disease progression despite seemingly good IOP control, and • PXF glaucoma.1,2 AGIS Investigators. Am J Ophthalmol 2000;130:429–40. Asrani S, et al. J Glaucoma 2000;9:134–42. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.

9. Setting target IOP • Formulation of target IOP is one of the most important steps in treatment. • Target IOP is defined as the upper limit of a stable range of measured IOPs deemed likely to retard further optic nerve damage.1 American Academy of Ophthalmology. Primary Open-Angle Glaucoma. Preferred Practice Pattern. San Francisco, CA: American Academy of Ophthalmology; 2005. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.

10. Setting target IOP (cont’d) • When setting target IOP, each eye is staged into 1 of 4 severity groups —suspect, early, moderate, or advanced glaucoma —based on: • assessment of the optic nerve and (or) VF • patient factors • age • life expectancy • QOL • risk factors for progression • patient’s own input • There is a fine line between setting an appropriate goal to prevent optic nerve damage, and being overly aggressive in IOP lowering. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.

11. Staging each eye forglaucoma damage Adapted from Damji KF, et al. Can J Ophthalmol 2003;38:189–97. *Refers to vertical C/D ratio in an average size nerve. If the nerve is small, then a smaller C/D ratiomay still be significant; conversely, a large nerve may have a large vertical C/D ratio and still bewithin normal limits. †Also consider baseline 10-2 VF (or similar). Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.

12. Suggested upper limit of initialtarget IOP for each eye Adapted from Damji KF, et al. Can J Ophthalmol 2003;38:189–97. Note: Target IOP may need to be adjusted during the course of follow-up. Extremes of CCT may be helpful in the setting of target IOP. For example, if the cornea is very thin, this may encourage a more aggressive approach with more frequent follow-up. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.

13. Staging severity of glaucoma Recommendation Stage each eye of the patient as normal, suspect, early, moderate or advanced glaucoma based on optic nerve and (or) VF exam [Consensus]. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.

14. Target IOP — setting initial range Recommendation Set upper limit of initial target IOP range for each eye at first visit and then re-evaluate at each visit based on stability/change in structure and function of the optic nerve (i.e., ONH exam with or without additional imaging information as well as VF data) [Consensus]. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.