Stepping Up Glaucoma Management: When and How?

Glaucoma management aims to preserve patients’ quality of life by halting progressive visual loss. Intraocular pressure reduction is the pivotal strategy: we establish a “target” pressure based on extent of visual damage, threat to visual performance, risk profile for further damage, pre-treatment pressure levels, family history and a patient’s life expectancy. Once an acceptable treatment regimen has been instituted, review ascertains whether damage has advanced and/or the risk of progressive damage has changed. Increased damage and/or increased risk of progressive damage suggest accelerated treatment, and lowered target pressures. When should management be stepped up? When a glaucoma patient, or a glaucoma suspect is getting worse and it matters, and when an individual is at increased risk of getting worse and it matters. At each review, the ophthalmologist seeks change in disease status: is it stable, uncertain whether or not it is stable, or progressing? Equally, the level of risk of further damage is assessed: is it unchanged, uncertain whether it is unchanged, or increased? If both disease status and risk are stable, the patient continues as is; if either or both have changed, treatment either can be initiated for suspects, or accelerated for patients. This means, intervene to reduce the perceived risk of further damage, and this means reducing or further reducing pressure.