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Glaucoma
Monitoring the Progressing Glaucoma Patient – What Are the Challenges?
Karolien Termote and Thierry Zeyen
Department of Ophthalmology, University Hospitals Leuven
Abstract
Diagnosing glaucoma progression is complex. It is essential to assess both structure and function to detect progression. Establishing a reliable
baseline is crucial in this process. A functional baseline requires repeated visual field testing. Documentation of the optic disc appearance is
necessary for the acquisition of the structural baseline. This can be achieved by the complementary modes of both clinical and imaging device-
based optic disc documentation. Imaging-based methods to assess progression and rate of progression are likely to prove important in the
future, but currently more guidance for their use in clinical practice is required. Rate of progression provides important information about
the risk of vision loss. Guidelines therefore recommend determining the rate of progression for the individual patient when planning
management. Adherence issues need to be addressed before changing treatment strategy, since poor compliance may play a considerable role
in the progression of disease in many patients. In conclusion, we must strive to improve the management of glaucoma to limit the impact
disease progression has on the patient’s quality of life.
Keywords
Glaucoma, progression, visual field, stereo photography, confocal scanning laser ophthalmoscopy (CLSO), Heidelberg Retina Tomography (HRT),
glaucoma detection system with variable corneal compensation (GDx VCC), optical coherence tomography (OCT)
Disclosure: The authors have no conflicts of interest to declare.
Received: 26 August 2009 Accepted: 28 September 2009
Correspondence: Karolien Termote, Department of Ophthalmology, University Hospitals Leuven, Kapucijnenvoer 33, B-3000 Leuven, Belgium.
E: karolien.termote@uz.kuleuven.be
Support: Supported by Pfizer. The views expressed are those of the authors and not necessarily those of Pfizer.
Glaucoma is a chronic, progressive optic neuropathy mostly associated structure and function to detect progression. It was generally
with elevated intraocular pressure (IOP).
1
Without adequate accepted that optic disc changes precede visual field (VF) damage.
5
management, glaucoma can lead to reduced quality of life (QoL) and However, the Ocular Hypertension Treatment Study (OHTS) and the
irreversible visual loss.
1
Glaucoma affects approximately 67 million European Glaucoma Prevention Study (EGPS) have shown that
people worldwide and is the second leading cause of blindness in structural and functional damage seldom overlap in patients
the world.
2
Detection of glaucoma progression is crucial for the converting from ocular hypertension (OHT) to glaucoma,
6,7
and that
identification of patients at risk of visual loss.
3
VF changes may precede optic disc damage. The same was shown
in glaucoma patients with progression.
8–10
Delaying Progression Poses Several Challenges
Delaying progression assumes first detection of progression, then Both optic disc photos/digital imaging and VF are complementary
determination of the rate of progression and, finally, adjustment of to monitor change, and VF is probably not the ideal gold standard to
treatment. Treatment decisions should be based on the available validate imaging devices. Statistically significant structure–function
scientific evidence and tailored to the individual patient. The goal of correlations exist only in patients with advanced glaucoma.
11
In terms
glaucoma treatment is to maintain the patient’s visual function and of the definitions of structural defects, the European Glaucoma
related QoL at a sustainable cost in terms of inconvenience, side Society (EGS) Guidelines describe clinical optic disc assessment, but
effects and financial implications.
3
the analysis is subjective.
3
Analysis of structural defects should ideally
be both qualitative and quantitative.
Detection of Progression
Definitions In the evaluation of functional defects, the EGS has made
European and US guidelines describe progression as a worsening recommendations in terms of the frequency of VF testing using
of structural and/or functional defects.
3,4
However, more detailed specific analysis tools.
3
The frequency of testing is to be adapted
definitions of progression have not yet been established. It is well- to the severity of glaucoma damage and the rate of progression.
3
known that progression can occur at normal IOP levels; therefore, This will be discussed below, in the section on determining the rate
we cannot rely on tonometry alone. It is essential to assess both of progression.
© TOUCH BRIEFINGS 2009 23
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