Use of Guidelines in the Management of Patients With Glaucoma

Glaucoma is a leading cause of vision loss and blindness worldwide, especially among the elderly. While there are many forms of glaucoma, there are 2 major groups: `open-angle' (OAG) and `angle closure'. The latter is now successfully treated by laser iridotomy. The former, OAG, is a chronic condition that accounts for the majority of glaucomas in developed countries. For both major groups of glaucoma, different management guidelines exist. Both the American Academy of Ophthalmology (AAO) and the American Optometric Association (AOA) have guidelines which cover both groups of glaucoma. Comparison of these guidelines reveals striking similarity, suggesting relative uniformity of professional opinion regarding `best practice' care of patients with glaucoma. However, there are a few important differences between the 2 guidelines promulgated by the 2 organisations. For OAG, the most important and striking difference is in the criteria for case identification and case severity classification. The AAO uses, essentially, an optic nerve head criteria for case identification and then classifies severity according to visual field criteria only. In contrast, the AOA uses both optic nerve and visual field criterion to both make a diagnosis and to classify the severity of disease. Related to this, early glaucoma in the AAO classification is explicitly glaucoma without any visual field loss, whereas the AOA classification of early glaucoma is already equivalent to at least moderate glaucoma in the AAO scheme. Additional differences between both guidelines centre mostly on more intensive use of services and testing in the optometric guidelines. Little data have been published to date on whether or not care provided to patients conforms to these guidelines. What has been described indicates relatively good compliance with most elements of care, but with major deficiencies in some important aspects of care i.e. the content of care and the follow-up nature of care. As such, significantly more work needs to be undertaken to better provide care to patients with glaucoma.