An Evidence-Based Approach to Glaucoma Care

  • Louis R. Pasquale


Put several glaucoma specialists in a room and solicit opinions on just about any clinical issue and you are bound to receive multiple opinions on how to manage the problem. For example, a patient presents with shallow angles on van Herrick screening. What gonioscopic features would prompt you to perform a laser iridotomy? Would you perform a dark room provocative test to confirm your impression that the angle was potentially occludable? Do you perform a pharmacological challenge test before proceeding to prophylactic laser iridotomy? Would you order an ultrasound biomicroscopic test to confirm your impression? If you do decide that prophylactic laser iridotomy is indicated, what is the best surgical technique for achieving patency? Is there evidence to support a “best approach” to the patient with the narrow angle? In this chapter, we discuss how evidence-based medicine (EBM) can be used to provide the very best answers to questions such as these. This approach can be applied not only to glaucoma problems, but also to any clinical problem in medicine.


Central Corneal Thickness Primary Angle Closure Glaucoma Laser Trabeculoplasty Glaucoma Specialist Exfoliation Glaucoma 


  1. 1.
    The reliable source of evidence in health care. In: Julian PT, Higgins, Sally, eds. The Cochrane Handbook for Systematic Reviews of Interventions. Wiley, Interscience, Sussex England; 2008.Google Scholar
  2. 2.
    Bhandari M, Zlowodzki M, Cole PA. From eminence-based practice to evidence-based practice: a paradigm shift. Minn Med. 2004;87:51–54.PubMedGoogle Scholar
  3. 3.
    Gorman C. Are doctors just playing hunches? Time. 2007;169(9):52–54.PubMedGoogle Scholar
  4. 4.
    Gordon MO, Beiser JA, Brandt JD, et al. The ocular hypertension treatment study: baseline factors that predict the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002;120:714-720. discussion 829–830.PubMedGoogle Scholar
  5. 5.
    Leske MC, Wu SY, Hennis A, Honkanen R, Nemesure B. Risk factors for incident open-angle glaucoma: the Barbados Eye Studies. Ophthalmology. 2008;115:85–93.CrossRefPubMedGoogle Scholar
  6. 6.
    Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71–72.PubMedGoogle Scholar
  7. 7.
    Flynn CA, D’Amico F, Smith G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract. 1998;47:264–270.PubMedGoogle Scholar
  8. 8.
    Michael JG, Hug D, Dowd MD. Management of corneal abrasion in children: a randomized clinical trial. Ann Emerg Med. 2002;40:67–72.CrossRefPubMedGoogle Scholar
  9. 9.
    Le Sage N, Verreault R, Rochette L. Efficacy of eye patching for traumatic corneal abrasions: a controlled clinical trial. Ann Emerg Med. 2001;38:129–134.CrossRefPubMedGoogle Scholar
  10. 10.
    Daly WJ, Brater DC. Medieval contributions to the search for truth in clinical medicine. Perspect Biol Med. 2000;43:530–540.PubMedGoogle Scholar
  11. 11.
    North R. Benjamin Rush, MD: assassin or beloved healer? Proc (Bayl Univ Med Cent). 2000;13:45–49.Google Scholar
  12. 12.
    Bean RB. Sir William Osler. Aphorisms. Springfield: Blackwell; 1961:164Google Scholar
  13. 13.
    Morris JN. Recalling the miracle that was penicillin: two memorable patients. J R Soc Med. 2004;97:189–190.CrossRefPubMedGoogle Scholar
  14. 14.
    Mansberger SL. A risk calculator to determine the probability of glaucoma. J Glaucoma. 2004;13:345–347.CrossRefPubMedGoogle Scholar
  15. 15.
    Medeiros FA, Weinreb RN, Sample PA, et al. Validation of a predictive model to estimate the risk of conversion from ocular hypertension to glaucoma. Arch Ophthalmol. 2005;123:1351–1360.CrossRefPubMedGoogle Scholar
  16. 16.
    Gordon MO, Torri V, Miglior S, et al. Validated prediction model for the development of primary open-angle glaucoma in individuals with ocular hypertension. Ophthalmology. 2007;114:10–19.CrossRefPubMedGoogle Scholar
  17. 17.
    von Helmholtz HLF. Beschreibung eines Augen-Spiegels. Berlin, Germany: A Förstner'sche Verlagsbuchhandlung; 1851.Google Scholar
  18. 18.
    Dellaporta A. Historical notes on gonioscopy. Surv Ophthalmol. 1975;20:137–149.CrossRefPubMedGoogle Scholar
  19. 19.
    Hertzog LH, Albrecht KG, LaBree L, Lee PP. Glaucoma care and conformance with preferred practice patterns. Examination of the private, community-based ophthalmologist. Ophthalmology. 1996;103:1009–1013.PubMedGoogle Scholar
  20. 20.
    Coleman AL, Yu F, Evans SJ. Use of gonioscopy in medicare beneficiaries before glaucoma surgery. J Glaucoma. 2006;15:486–493.CrossRefPubMedGoogle Scholar
  21. 21.
    Kronfeld P. Eserine and pilocarpine: our 100-year-old allies. Surv Ophthalmol. 1970;14:479.PubMedGoogle Scholar
  22. 22.
    Beasley H, Fraunfelder FT. Retinal detachments and topical ocular miotics. Ophthalmology. 1979;86:95–98.PubMedGoogle Scholar
  23. 23.
    Zimmerman TJ, Kass MA, Yablonski ME, Becker B. Timolol maleate: efficacy and safety. Arch Ophthalmol. 1979;97:656–658.PubMedGoogle Scholar
  24. 24.
    Lippa EA, Carlson LE, Ehinger B, et al. Dose response and duration of action of dorzolamide, a topical carbonic anhydrase inhibitor. Arch Ophthalmol. 1992;110:495–499.PubMedGoogle Scholar
  25. 25.
    Derick RJ, Robin AL, Walters TR, et al. Brimonidine tartrate: a one-month dose response study. Ophthalmology. 1997;104:131–136.PubMedGoogle Scholar
  26. 26.
    Camras CB, Schumer RA, Marsk A, et al. Intraocular pressure reduction with PhXA34, a new prostaglandin analogue, in patients with ocular hypertension. Arch Ophthalmol. 1992;110:1733–1738.PubMedGoogle Scholar
  27. 27.
    Eddy DM, Billings J. The quality of medical evidence: implications for quality of care. Health Aff (Millwood). 1988;7:19–32.CrossRefGoogle Scholar
  28. 28.
    Kass MA, Heuer DK, Higginbotham EJ, et al. The ocular hypertension treatment study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002;120:701-713. discussion 829–830.PubMedGoogle Scholar
  29. 29.
    Heijl A, Leske MC, Bengtsson B, Hyman L, Bengtsson B, Hussein M. Reduction of intraocular pressure and glaucoma progression: results from the Early Manifest Glaucoma Trial. Arch Ophthalmol. 2002;120:1268–1279.PubMedGoogle Scholar
  30. 30.
    The Glaucoma Laser Trial (GLT). 2. Results of argon laser trabeculoplasty versus topical medicines. The Glaucoma Laser Trial Research Group. Ophthalmology 1990;97:1403–1413Google Scholar
  31. 31.
    Lichter PR, Musch DC, Gillespie BW, et al. Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery. Ophthalmology. 2001;108:1943–1953.CrossRefPubMedGoogle Scholar
  32. 32.
    Denis P, Lafuma A, Khoshnood B, Mimaud V, Berdeaux G. A meta-analysis of topical prostaglandin analogues intra-ocular pressure lowering in glaucoma therapy. Curr Med Res Opin. 2007;23:601–608.CrossRefPubMedGoogle Scholar
  33. 33.
    Cheng JW, Wei RL. Meta-analysis of 13 randomized controlled trials comparing bimatoprost with latanoprost in patients with elevated intraocular pressure. Clin Ther. 2008;30:622–632.CrossRefPubMedGoogle Scholar
  34. 34.
    Vass C, Hirn C, Sycha T, Findl O, Bauer P, and Schmetterer L. Medical interventions for primary open angle glaucoma and ocular hypertension. Cochrane Database Syst Rev 2007:CD003167Google Scholar
  35. 35.
    Kuhn TS. The structure of scientific revoluations, 3rd ed. Chicago: The University of Chicago Press; 1996:212Google Scholar
  36. 36.
    Konstas AG, Kozobolis VP, Katsimpris IE, et al. Efficacy and safety of latanoprost versus travoprost in exfoliative glaucoma patients. Ophthalmology. 2007;114:653–657.CrossRefPubMedGoogle Scholar
  37. 37.
    Konstas AG, Hollo G, Irkec M, et al. Diurnal IOP control with bimatoprost versus latanoprost in exfoliative glaucoma: a crossover, observer-masked, three-centre study. Br J Ophthalmol. 2007;91:757–760.CrossRefPubMedGoogle Scholar
  38. 38.
    Parmaksiz S, Yuksel N, Karabas VL, Ozkan B, Demirci G, Caglar Y. A comparison of travoprost, latanoprost, and the fixed combination of dorzolamide and timolol in patients with pseudoexfoliation glaucoma. Eur J Ophthalmol. 2006;16:73–80.PubMedGoogle Scholar
  39. 39.
    Konstas AG, Mylopoulos N, Karabatsas CH, et al. Diurnal intraocular pressure reduction with latanoprost 0.005% compared to timolol maleate 0.5% as monotherapy in subjects with exfoliation glaucoma. Eye 2004;18:893–899CrossRefPubMedGoogle Scholar
  40. 40.
    Konstas AG, Kozobolis VP, Tersis I, Leech J, Stewart WC. The efficacy and safety of the timolol/dorzolamide fixed combination vs latanoprost in exfoliation glaucoma. Eye. 2003;17:41–46.CrossRefPubMedGoogle Scholar
  41. 41.
    Barratt A, Wyer PC, Hatala R, et al. Tips for learners of evidence-based medicine: 1. Relative risk reduction, absolute risk reduction and number needed to treat. CMAJ. 2004;171:353–358.PubMedGoogle Scholar
  42. 42.
    Higginbotham EJ, Gordon MO, Beiser JA, et al. The Ocular Hypertension Treatment Study: topical medication delays or prevents primary open-angle glaucoma in African American individuals. Arch Ophthalmol. 2004;122:813–820.CrossRefPubMedGoogle Scholar
  43. 43.
    Musch DC, Gillespie BW, Niziol LM, et al. Cataract extraction in the collaborative initial glaucoma treatment study: incidence, risk factors, and the effect of cataract progression and extraction on clinical and quality-of-life outcomes. Arch Ophthalmol. 2006;124:1694–1700.CrossRefPubMedGoogle Scholar
  44. 44.
    Pasquale LR, Dolgitser M, Wentzloff JN, et al. Health care charges for patients with ocular hypertension or primary open-angle glaucoma. Ophthalmology. 2008;115(4):633–638.CrossRefPubMedGoogle Scholar
  45. 45.
    Kymes SM, Kass MA, Anderson DR, Miller JP, Gordon MO. Management of ocular hypertension: a cost-effectiveness approach from the Ocular Hypertension Treatment Study. Am J Ophthalmol. 2006;141:997–1008.CrossRefPubMedGoogle Scholar
  46. 46.
    Speaker MG, Guerriero PN, Met JA, Coad CT, Berger A, Marmor M. A case-control study of risk factors for intraoperative suprachoroidal expulsive hemorrhage. Ophthalmology. 1991;98:202-209. discussion 210.PubMedGoogle Scholar
  47. 47.
    Obuchowska I, Mariak Z. Risk factors of massive suprachoroidal hemorrhage during extracapsular cataract extraction surgery. Eur J Ophthalmol. 2005;15:712–717.PubMedGoogle Scholar
  48. 48.
    Moshfeghi DM, Kim BY, Kaiser PK, Sears JE, Smith SD. Appositional suprachoroidal hemorrhage: a case-control study. Am J Ophthalmol. 2004;138:959–963.CrossRefPubMedGoogle Scholar
  49. 49.
    Ehlers JP, Spirn MJ, Lam A, Sivalingam A, Samuel MA, Tasman W. Combination intravitreal bevacizumab/panretinal photocoagulation versus panretinal photocoagulation alone in the treatment of neovascular glaucoma. Retina. 2008;28:696–702.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Louis R. Pasquale
    • 1
  1. 1.Department of OphthalmologyMassachusetts Eye and Ear InfirmaryBostonUSA

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