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Management of the Progressing Glaucoma Patient
The strong link between the  amount of IOP reduction and drop in therapies of bimatoprost or latanoprost with timolol have been
disease progression risk has recently been confirmed by the Canadian compared in a patient population previously taking  beta-blocker
Glaucoma Study (CGS). The CGS was a multicentre, prospective, monotherapy.
15
The results showed that both fixed combination
longitudinal clinical study that started with the aim of identifying therapies were superior to monotherapy with beta-blockers in
ocular and systemic risk factors for the progression of perimetric reducing IOP. The combination with bimatoprost was superior to the
damage in glaucoma.
6
In the CGS, risk factors of a cardiovascular one with latanoprost. These results confirm  data from the literature
nature, such  as peripheral vasospasm, migraine or systolic and comparing prostaglandin analogues administrated in monotherapy.
13
diastolic blood pressure, did not appear to be significantly associated These data also agree with the results of a randomised multicentre
with the progression risk of glaucomatous damage. However, every study where the efficacy of fixed combination therapies has been
1mmHg increase in IOP has been associated with an approximately compared in a population of glaucoma patients previously treated with
20% increased risk of progression. prostaglandin analogue monotherapy (see Figure 4).
16
Although the
decrease of IOP is today the only evidence-based instrument capable
What stands out from the trial data is that therapeutic management of altering the visual function prognosis of the patient suffering from
of the glaucoma patient needs be early and that effective prevention glaucoma, it should be considered that the ultimate goal of therapeutic
of increased IOP is essential, since long-term prognosis is linked to intervention is not IOP reduction. The goal is deceleration of disease
the effectiveness of therapy started at the moment of diagnosis. progression rate to a level that minimises the impact of the functional
deficit on the quality of life of each individual patient.
If the management of patients with a middle/low-risk profile 
consists  of  choosing an effective monotherapy, the approach is Conclusion
different for patients with higher-risk profiles. Those with high-risk In conclusion, management of the glaucoma patient should be
profiles include young patients with advanced damage and a fast based on perimetric data, which should be considered as the
progressing disease or those with a  high probability of rapid best way to judge the efficacy of ocular hypotensive therapy. This
disease progression who could require more aggressive therapies should allow a more solid relationship to be built  between the
from the time of diagnosis or very early during follow-up. physician and the patient based on mutual exchange of information.
The clinician will gain information regarding the variation in disease
The probability that  two years after diagnosis a glaucoma patient progression rate in response to the therapeutic choice, with evident
needs more than one drug to decrease his or her IOP to an acceptable functional prognostic implications. On the patient’s side, there is the
value based on individual risk profile has been estimated to be 75%.
7
potential to discuss compliance and the perception of the disease
If it is necessary to combine more drugs to lower IOP, not only during follow-up. n
efficacy but also efficiency must be considered. To be efficient from a
clinical point of view, a therapy must not only be effective on IOP, but
Marco Centofanti is Aggregate Professor at the University of Rome Tor Vergata and
must also have a good local and systemic tolerability. It must 
Head of the Glaucoma Research Unit of the IRCCS Bietti Eye Foundation in Rome.
require few daily applications to aid the patient’s compliance He received his degree in medicine from the University of Rome ‘La Sapienza’
during periods between visits.
in 1987 and specialised in ophthalmology in 1991 at the University of Tor Vergata,
Rome. He obtained his PhD in 1996, working on nerve growth factor and retinal
damage in high increased intraocular pressure animal models.
From this point of view the fixed combinations with beta-blockers and
prostaglandin derivatives constitute an important tool. These
Francesco Oddone is a Consultant in the Glaucoma Research Unit at the IRCCS Bietti
combinations are  effective in lowering IOP and have an excellent
Eye Foundation in Rome. His main scientific interests are early detection of glaucoma
tolerability, and daily posology is reduced to a minimum. Recently,
and glaucoma progression, glaucoma imaging, pharmacology, genetics and corneal
biomechanics. He received his degree in medicine from the University of Tor Vergata in
some studies have been published reporting the assessment of
2000 and specialised in ophthalmology in 2004. Dr Oddone obtained his PhD in 2004,
combinations of beta-blockers and prostaglandin analogues in
working on the genetics of pigmentary glaucoma. He completed a fellowship in the
patients previously treated with monotherapies. In the study published
Glaucoma Research Unit at Moorfields Eye Hospital in London.
by Martinez et al. in 2008, the efficacy of the fixed combination
1. European Glaucoma Society, Terminology and Guidelines for Ophthalmol, 2008;126:1030–36. 12. Krammer JA, Katzman B, Ackerman SL, et al., The effect of
Glaucoma, 2nd Edn, Savona, Italy, Dogma, 2008. 7. Lichter PR, Musch DC, Gillespie BW, et al., Interim clinical bimatoprost 0.03% vs travoprost 0.004% in patients on
2. Oliver JE, Hattenhauer MG, Herman D, et al., Blindness and outcomes in the Collaborative Initial Glaucoma Treatment latanoprost 0.005% requiring additional IOP lowering,
glaucoma: a comparison of patients progressing to Study comparing initial treatment randomized to poster presentation, American Society of Cateract and
blindness from glaucoma with patients maintaining vision, medications or surgery, Ophthalmology, 2001;108:1943–53. Refractive Surgery, Chicago, Illinois, 2008.
Am J Ophthalmol, 2002;133:764–72. 8. Anon. The Advanced Glaucoma Intervention Study (AGIS): 13. Aptel F, Cucherat M, Denis P, Efficacy and tolerability of
3. Guse CE, Porinsky R, Risk factors associated with 4, Comparison of treatment outcomes within race. prostaglandin analogs: a meta-analysis of randomized
hospitalization for unintentional falls: Wisconsin hospital Seven-year results, Ophthalmology, 1998;105:1146–64. controlled trials, J Glaucoma, 2008;17:667–73.
discharge data for patients aged 65 and over, WMJ, 9. Collaborative Normal-Tension Glaucoma Study Group, 14. Wan Z, Woodward DF, Cornell  CL, et al., Bimatoprost,
2003;102:37–42. Comparison of glaucomatous progression between prostamide activity, and conventional drainage, Invest
4. Haymes SA, Leblanc RP, Nicolela MT, et al., Risk of falls untreated patients with normal-tension glaucoma and Opthalmol Vis Sci, 2007;48:4107–15.
and motor vehicle collisions in glaucoma, Invest Ophthalmol patients with therapeutically reduced intraocular 15. Martinez A, Sanchez M, Bimatoprost/timolol fixed
Vis Sci, 2007;48:1149–55. pressures, Am J Ophthalmol, 1998;126:487–97. combination vs latanoprost/timolol fixed combination in
5. Heijl A, Leske MC, Bengtsson B, et al., Reduction of 10. Bengtsson B, Heijl A, A visual field index for calculation of open-angle glaucoma patients, Eye, 2009;23:810–18.
intraocular pressure and glaucoma progression: results glaucoma rate of progression, Am J Ophthalmol, 16. Centofanti M, Oddone F, Vetrugno M, et al., Efficacy of the
from the Early Manifest Glaucoma Trial, Arch Ophthalmol, 2008;145:343–53. fixed combinations of bimatoprost or latanoprost plus
2002;120:1268–79. 11. Simmons ST, Berstein P, Hollander DA, A comparison of timolol in patients uncontrolled with prostaglandin
6. Chauhan BC, Mikelberg FS, Balaszi AG, et al., Canadian long-term intraocular pressure fluctuation in patients monotherapy: results of a multicenter, randomized,
Glaucoma Study Group, Canadian Glaucoma Study: 2. risk treated with bimatoprost or latanoprost, Am J Ophthalmol, investigator-masked, clinical study, Eur J Ophthalmol,
factors for the progression of open-angle glaucoma, Arch 2008;146:473–7. 2009;19:66–71.
EUROPEAN OPHTHALMIC REVIEW 39
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