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Canadian Ophthalmological Society

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

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Canadian Ophthalmological Society

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

  2. Progression

  3. Definition of progression • A patient’s glaucoma is deemed to have progressed if structural and (or) functional changes, associated with the disease, are verifiably detected on clinical examination and (or) testing. • The clinical significance of this progression, and the actions taken, will be influenced by: • the extent of damage prior to the change, and • the threat of visual handicap if further progression were to occur. 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. Methods of detecting progression • Progression may be detected, clinically or with the aid of various technological investigations, as loss of tissue (structural) and/or vision (function). • Careful ophthalmoscopy and precise documentation (i.e., photography or imaging) may confirm loss of RNFL or optic disc tissue over time. 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. Methods of detectingprogression (cont’d) • Confirming progressive vision loss requires threshold evaluation of the peripheral field. • In both instances, the potential for greater sensitivity and quantification of change mayexist for technologically based evaluations compared with clinical examinations alone. 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. Endpoints for conversion to, or progression of, glaucoma in major RCTs 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.

  7. Progression — technology choices Recommendation Assessing disease severity is important to determine which tests might be most useful for each individual. Patients with glaucoma should be monitored with both structural and functional tests, as progression can be detected by either method alone [Level 21]. 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. 1. Artes PH, et al. Prog Retin Eye Res2005;24:333–54.

  8. VF progression endpoints forthe major glaucoma RCTs 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. Advantages and disadvantages ofevent-based and trend-basedapproaches to VF progression 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. Progression — correlationbetween structure and function Recommendation It is recommended that a correlation between structural and functional changes be sought in suspected progression, even though it is more common for a change to be detected with one or the other independently [Level 11-4]. 1. Collaborative Normal-Tension Glaucoma Study Group.Am J Ophthalmol 1998;126:487–97. 2. Kass MA, et al. Arch Ophthalmol 2002;120:701–13. 3. Heijl A, et al. Arch Ophthalmol 2002;120:1268–79. 4. Miglior S, et al Ophthalmology 2002;109:1612–21. 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. Risk factors and their relationshipto VF progression examinedin the landmark RCTs *Positively associated if more severe baseline VF damage resulted in greater degree of VF progression †Positive association in patients with low mean IOPs and not high mean IOPs 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. Risk factors and their relationshipto VF progression examinedin the landmark RCTs ‡Positive association in ATT and not TAT sequence 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. Progression significant forthe patient • The significance of a detectable structural and (or) functional change would be different for different patients. • The ophthalmologist’s response should reflect the significance to the patient. 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. Progression significant forthe patient (cont’d) • Significance and action taken would be influenced by some of the following considerations: • What is the baseline level of glaucomatous damage (i.e., is the VF full with a nearly normal-appearing disc, or is fixation threatened in 3 of 4 quadrants)? • What is the status of the fellow eye? • What is the health of the patient and life expectancy? • What are the visual demands of the patient (e.g., is he or shestill driving)? • What is the next step? Is it heightened surveillance or is it incisional surgery? • What is the patient’s interpretation of the change and the proposed actions? 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.

  15. Visual field — progression confirmation Recommendation The clinician’s response to a new progressive event should be to confirm the change with a repeat test. VFs may need to be performed more frequently during periods of apparent progression. Ultimately, it is most important to calculate the rate of progression over time [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.

  16. Number of annual VF tests neededto detect total mean deviationchange over 2, 3, and 5 years Adapted from: Chauhan BC, et al. Br J Ophthalmol 2008;92:569–73. 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.

  17. Visual field — baseline Recommendation In order to establish a good baseline and to detect possible rapid progression, several VFs should be performed at regular intervals in the first 2 years [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.

  18. Frequency of follow-up • Frequency of follow-up is influenced by a number of factors. • Patients with stable glaucoma, or ocular hypertension who are on treatment, need assessment at least once a year. • Depending on disease severity, other patients will require more frequent assessments. • Clinical judgment and common sense should be exercised when dealing with very elderly patients who travel long distances for follow-up, particularly duringthe winter. 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.

  19. Recommended clinical assessment*intervals for stable† chronic glaucomas *Assessments might include any of the components listed in Table 2 in addition to documentation of the optic disc and VF testing. †More frequent evaluations may be necessary if indications listed in Table 17 are noted. ‡It may be necessary to see patients with advanced glaucoma very frequently (weeks or days) if their IOP is poorly controlled, progression appears rapid or fixation is threatened. 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.

  20. Indications for more frequent follow-upor heightened surveillance 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.

  21. Progression: Treatment goals • Some degree of progression may be unavoidable in glaucoma. • Goals for the clinician include: • measuring and minimizing the progression, • preserving or enhancing QOL, and • choosing a management scheme that is appropriate and acceptable to the patient. 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.

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