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Treatment for Glaucoma: Comparative Effectiveness

Comparative Effectiveness Reviews, No. 60

Investigators: Michael V Boland, MD, PhD, Ann M Ervin, PhD, David Friedman, MD, Henry Jampel, MD, Barbara Hawkins, PhD, Daniela Volenweider, MD, Yohalakshami Chelladurai, Darcy Ward, Catalina Suarez-Cuervo, MD, and Karen A Robinson, PhD.

Johns Hopkins University Evidence-based Practice Center
Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Apr.
Report No.: 12-EHC038-EF
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Structured Abstract

Objectives:

Glaucoma is a leading cause of visual impairment and blindness worldwide. Treatment focuses on the reduction of intraocular pressure (IOP), which secondarily prevents worsening of visual field loss; in this way, available treatments may prevent visual impairment and blindness. The objective of this Comparative Effectiveness Review is to summarize the evidence regarding the safety and effectiveness of medical, laser, and other surgical treatments for open-angle glaucoma in adults.

Data Sources:

We searched MEDLINE®, Embase, LILACS, and CENTRAL through October 6, 2011 to identify clinical trials. We searched MEDLINE and CENTRAL (from 2009 to March 2, 2011) and screened an existing database to identify relevant systematic reviews.

Review Methods:

Two reviewers independently assessed citations for eligibility. One reviewer assessed the risk of bias and extracted descriptions of the study. A second reviewer verified the data. Two reviewers also screened the results for systematic reviews. Details about the eligible systematic reviews were abstracted, including elements related to the methodological rigor.

Results:

We identified 23 systematic reviews. Twelve reviews addressed medical treatments, 9 addressed surgical treatment, and 1 compared medical versus surgical treatments. One review addressed different surgical treatments as well as medical versus surgical treatments. We identified 73 RCTs and 13 observational studies addressing adverse effects. We identified no studies that evaluated treatments with regard to their impact on visual impairment. We also found insufficient evidence comparing treatment versus no treatment on patient-reported outcomes. No studies addressed the possible link between intermediate outcomes (IOP, optic nerve structure, or visual field) and visual impairment or patient-reported outcomes. There is moderate evidence that medical and surgical treatments can lower IOP and reduce the risk of progression by both visual field and optic nerve criteria. Among medical treatments, the prostaglandin agents are superior to other classes with regard to lowering IOP. While laser trabeculoplasty decreases IOP, the technology used does not make a difference in pressure lowering. With regard to incisional surgeries, trabeculectomy provides more pressure lowering than the class of nonpenetrating procedures. As expected, incisional surgeries produce more significant side effects than do medical treatments.

Conclusions:

We did not find evidence addressing direct or indirect links between glaucoma treatment and visual impairment or patient-reported outcomes. This should be an area of focus in future trials of adequate size and duration to detect differences between treatment groups. However, we did find that a number of medical and surgical treatments clearly lower IOP and can prevent visual field loss and optic nerve damage. While we found direct comparisons between some treatments, there are significant gaps in our knowledge of comparative effectiveness.

Contents

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. HHSA 290-2007-10061-I, Prepared by: Johns Hopkins University Evidence-based Practice Center, Baltimore, Maryland

Suggested citation:

Boland MV, Ervin AM, Friedman D, Jampel H, Hawkins B, Volenweider D, Chelladurai Y, Ward D, Suarez-Cuervo C, Robinson KA. Treatment for Glaucoma: Comparative Effectiveness. Comparative Effectiveness Review No. 60. (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. HHSA 290-2007-10061-I.) AHRQ Publication No. 12-EHC038-EF. Rockville, MD: Agency for Healthcare Research and Quality. April 2012. www.effectivehealthcare.ahrq.gov/reports/final.cfm.

This report is based on research conducted by the Johns Hopkins University Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHSA 290-2007-10061-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report.

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AHRQ (US Agency for Healthcare Research and Quality)

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