New AOA clinical guideline puts focus on elevating care of glaucoma patients

A leading cause of irreversible blindness in the world, glaucoma, patients diagnosed with the condition and those at risk for it can benefit from recommendations in the newly released AOA evidence-based practice guideline, Care of the Patient with Primary Open-Angle Glaucoma, First Edition.

An estimated 112 million people across the globe are expected to have the condition by 2040. The guideline, researched and authored by the AOA Evidence-based Optometry (EBO) Committee, was approved by the AOA Board of Trustees in October. It focuses on primary open-angle glaucoma (POAG).

“Our profession today and looking forward will play an ever-growing role in management of the disease,” says Carl Urbanski, O.D., chair of the EBO committee.

“The new guideline covers multiple new technologies and medications for diagnosis and treatment of glaucoma that were not developed or available when the first (consensus-based) guideline was published. “

That consensus-based document was first published in 1994 with a revision in 1998 and review in 2001.

“AOA clinical practice guidelines elevate health care worldwide by giving doctors of optometry a proven platform for delivering quality clinical care to patients based on best available scientific research,” AOA President Steven T. Reed, O.D., says.

"Health care is better for the years of work and dedication of the EBO Committee," he adds. "The guideline is an essential resource for every optometric practice and optometry school."

Care recommendations

Among guideline recommendations for care:

• Examination of a person suspected of having POAG should include all aspects of a comprehensive eye and vision examination. Read the guideline to find out what to emphasize.
• Prostaglandin analogs should be considered as an initial therapy in patients with ocular hypertension or POAG, unless contraindicated.
• Patients prescribed topical intraocular pressure-lowering therapy may experience decreased tear film stability and elevated tear osmolarity.
• Pharmacological treatment of POAG should be used with caution during pregnancy and lactation.
• Selective laser trabeculoplasty should be considered as an initial/alternative or additive therapy to medication for intraocular pressure (IOP) control.
• The frequency and scope of follow-up examinations of patients should be individualized, based on the severity and stability of their disease and should occur at regular intervals to monitor progression and treatment efficacy.
• Early medical treatment should be considered for individuals with ocular hypertension who are at moderate or high risk of developing POAG.
• Eye doctors should be persistent in providing education and training to patients to improve adherence/compliance with therapy.
• Patients prescribed pharmacological treatment should receive instructions on eyedrop instillation.
• Ocular telehealth can provide increased access to care but should not be used alone or for the assessment or management of moderate or advanced disease.

The guideline’s authors call POAG “a serious and significant public health concern.” It has been referred to as the “silent thief of vision” because it occurs without warning and is pain-free.

The committee’s review of existing literature, grading of evidence and the resulting recommendations were underpinned by a rigorous 14-step process, based on standards set by the National Academies of Sciences, Engineering and Medicine.

“The committee developed this process to fulfill the goal of providing clinicians with information and guidance to optimize patient care, based on systematic review of evidence,” Dr. Urbanski says. “Once the multidisciplinary team is assembled, we develop questions we would like the guideline to answer, search current literature for studies, review the results and develop the content. The committee identified over 2,400 articles through literature searches, followed the process and developed this final product concluding five years of work.”

The guideline described glaucoma as a group of ocular disorders characterized by progressive optic neuropathy. Its risk factors include aging, IOP and family history.

Among sections in the new guideline are its co-morbidities, examination, diagnosis, treatment and management options, and socio-economic considerations.

On a daily basis, Dr. Urbanski says, patients being treated for glaucoma or at risk for it are turning to their doctors of optometry to maintain their quality of life.

“The new guideline puts forth a systematic way to approach the diagnosis, initiation of treatment and monitoring of patients with glaucoma,” he says. “Our clinicians and their patients will be confident with the care following this information, which is supported by the most current evidence available. Every article reviewed was graded for strength of evidence, clinical recommendation as well as harms and benefits.”