Glaucoma Primario

Primary Open-Angle
Glaucoma Suspect
Preferred Practice
Pattern®
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Secretary for Quality of Care
Timothy W. Olsen, MD
Academy Staff
Ali Al-Rajhi, PhD, MPH
Andre Ambrus, MLIS
Meghan Daly
Flora C. Lum, MD
Medical Editor: Susan Garratt
Approved by: Board of Trustees

September 12, 2020
Copyright © 2020 American Academy of Ophthalmology®

All rights reserved
AMERICAN ACADEMY OF OPHTHALMOLOGY and PREFERRED PRACTICE PATTERN are

registered trademarks of the American Academy of Ophthalmology. All other trademarks are the property of
their respective owners.
Preferred Practice Pattern® guidelines are developed by the Academy’s H. Dunbar Hoskins Jr., MD Center
for Quality Eye Care without any external financial support. Authors and reviewers of the guidelines are
volunteers and do not receive any financial compensation for their contributions to the documents. The
guidelines are externally reviewed by experts and stakeholders before publication.
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Primary Open-Angle Glaucoma Suspect PPP
GLAUCOMA PREFERRED PRACTICE

PATTERN® DEVELOPMENT PROCESS AND
PARTICIPANTS
The Glaucoma Preferred Practice Pattern® Panel members wrote the Primary Open-Angle Glaucoma
Suspect Preferred Practice Pattern® guidelines (PPP). The PPP Panel members discussed and reviewed
successive drafts of the document, meeting in person twice and conducting other review by e-mail
discussion, to develop a consensus over the final version of the document.
Glaucoma Preferred Practice Pattern Panel 2019-2020

Steven J. Gedde, MD, Chair
John T. Lind, MD
Martha M. Wright, MD, American Glaucoma Society Representative
Philip P. Chen, MD
Kelly W. Muir, MD
Kateki Vinod, MD
Tianjing Li, MD, MHS, PhD, Consultant, Cochrane Eyes and Vision US Project
Steven L. Mansberger, MD, MPH, Methodologist
We thank our partner, the Cochrane Eyes and Vision US Group, for identifying reliable systematic reviews
that we cite and discuss in support of the PPP recommendations.
The Preferred Practice Patterns Committee members reviewed and discussed the document during a
meeting in May 2020. The document was edited in response to the discussion and comments.
Preferred Practice Patterns Committee 2020

Roy S. Chuck, MD, PhD, Chair
Steven P. Dunn, MD
Christina J. Flaxel, MD
Steven J. Gedde, MD
Francis S. Mah, MD
Kevin M. Miller, MD
James P. Tweeten, MD
David K. Wallace, MD, MPH
David C. Musch, PhD, MPH, Methodologist
The Primary Open-Angle Glaucoma Suspect PPP was then sent for review to additional internal and external
groups and individuals in June 2020. All those who returned comments were required to provide disclosure
of relevant relationships with industry to have their comments considered (indicated with an asterisk below).
Members of the PPP Panel reviewed and discussed these comments and determined revisions to the
document.
Academy Reviewers Association of University Professors in

Board of Trustees and Committee of Secretaries* Ophthalmology*
Council* Consumer Reports Health Choices
General Counsel* Canadian Ophthalmological Society*
Ophthalmic Technology Assessment Committee European Glaucoma Society*
Glaucoma Panel* International Council of Ophthalmology
Basic and Clinical Science Course Section 10 International Society of Glaucoma Surgery
Subcommittee International Society of Refractive Surgery
Practicing Ophthalmologists Advisory Committee for National Eye Institute*
Education National Medical Association, Section on
Ophthalmology
Invited Reviewers North American Neuro-Ophthalmology Society
American College of Surgeons Outpatient Ophthalmic Surgery Society
American Glaucoma Society World Glaucoma Association*
American Ophthalmological Society Women in Ophthalmology*
Association for Research in Vision and Ophthalmology Wallace L.M. Alward, MD*
Ta Chen Chang, MD
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i
FINANCIAL DISCLOSURES
In compliance with the Council of Medical Specialty Societies’ Code for Interactions with Companies
(available at https://cmss.org/code-signers-pdf/), relevant relationships with industry are listed. The Academy
has Relationship with Industry Procedures to comply with the Code (available at www.aao.org/about-preferred-
practice-patterns). A majority (85%) of the members of the Glaucoma Preferred Practice Pattern Panel 2019-
2020 had no related financial relationship to disclose.
Glaucoma Preferred Practice Pattern Panel 2019-2020

Steven J. Gedde, MD: No financial relationships to disclose
Philip P. Chen, MD: Allergan—Consultant/Advisor
John T. Lind, MD: Aerie Pharmaceuticals, Allergan—Consultant/Advisor; Aerie Pharmaceuticals,
Allergan—Lecture Fees, Perrigo—Grant Support
Kelly W. Muir, MD: No financial relationships to disclose
Kateki Vinod, MD: No financial relationships to disclose
Martha M. Wright, MD: No financial relationships to disclose
Tianjing Li, MD, MHS, PhD: No financial relationships to disclose
Steven L. Mansberger, MD, MPH: Allergan—Grant Support
Preferred Practice Patterns Committee 2020

Roy S. Chuck, MD, PhD: No financial relationships to disclose
Steven P. Dunn, MD: No financial relationships to disclose
Christina J. Flaxel, MD: No financial relationships to disclose
Steven J. Gedde, MD: No financial relationships to disclose
Francis S. Mah, MD: Abbott Medical Optics Inc., Aerie Pharmaceuticals, Alcon Laboratories Inc.,
Allergan, Bausch + Lomb, Novartis Pharmaceuticals, Ocular Science, Omeros Corporation,
PolyActiva—Consultant/Advisor; Abbott Medical Optics Inc., Bausch + Lomb, Novartis
Pharmaceuticals—Lecture Fees; Abbott Medical Optics Inc.—Grant Support; Ocular Science—Equity
Owner
Kevin M. Miller, MD: Alcon Laboratories Inc., Johnson & Johnson Vision—Consultant/Advisor
James P. Tweeten, MD: No financial relationships to disclose
David K. Wallace, MD, MPH: No financial relationships to disclose
David C. Musch, PhD, MPH, Methodologist: No financial relationships to disclose
Secretary for Quality of Care

Timothy W. Olsen, MD: No financial relationships to disclose
Academy Staff
Ali Al-Rajhi, PhD, MPH: No financial relationships to disclose
Andre Ambrus, MLIS: No financial relationships to disclose
Meghan Daly: No financial relationships to disclose
Flora C. Lum, MD: No financial relationships to disclose
Susan Garratt: No financial relationships to disclose
The disclosures of relevant relationships to industry of other reviewers of the document from January
to October 2020 are available online at www.aao.org/ppp.
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TABLE OF CONTENTS
OBJECTIVES OF PREFERRED PRACTICE PATTERN GUIDELINES .................................................. ....... P157
METHODS AND KEY TO RATINGS ............................................................................................................. ..... .. P158
HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE .................................................. ....... P159
INTRODUCTION ..............................................................................................................................................
..... .. P160
Disease Definition.................................................................................................................................................
..... .. P160
Clinical Findings Characteristic of Primary Open-Angle Glaucoma Suspect ...................................................... ..... .. P160
Patient Population .................................................................................................................................................
..... .. P160
Clinical Objectives ................................................................................................................................................ ....... P160
BACKGROUND ................................................................................................................................................. ....... P160
Prevalence ............................................................................................................................................................. ....... P160
Risk Factors .......................................................................................................................................................... ....... P161 P160
DETECTION ...................................................................................................................................................... ....... P162 P161
CARE PROCESS ................................................................................................................................................ ....... P162
Patient Outcome Criteria....................................................................................................................................... ....... P162
Diagnosis ..............................................................................................................................................................
..... .. P162
History .......................................................................................................................................................... ....... P162
Evaluation of Visual Function ...................................................................................................................... ....... P163 P162
Physical Examination.................................................................................................................................... ..... .. P163
Diagnostic Testing ............................................................................................................................................. .. P163
Differential Diagnosis ................................................................................................................................... ....... P167 P165
Management.......................................................................................................................................................... ....... P167
Goals ............................................................................................................................................................. ....... P167 P168
Deciding When to Treat a Glaucoma Suspect Patient .................................................................................. ....... P168
Target Intraocular Pressure ........................................................................................................................... ..... .. P168
Choice of Therapy ........................................................................................................................................ ....... P169
Follow-up Evaluation.................................................................................................................................... ....... P174 P169
Provider and Setting .............................................................................................................................................. ....... P175 P174
Counseling and Referral ....................................................................................................................................... ....... P175
Socioeconomic Considerations ............................................................................................................................. ....... P175
APPENDIX 1. QUALITY OF OPHTHALMIC CARE CORE CRITERIA ................................................. ..... .. P177
APPENDIX 2. INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND
RELATED HEALTH PROBLEMS (ICD) CODES ............................................................................... ....... P179
APPENDIX 3. MANAGEMENT ALGORITHM FOR PATIENTS WITH PRIMARY
OPEN-ANGLE GLAUCOMA SUSPECT ............................................................................................... ....... P180
APPENDIX 4. LITERATURE SEARCHES FOR THIS PPP ........................................................................ ..... .. P181
RELATED ACADEMY MATERIALS ............................................................................................................ ....... P181
REFERENCES.................................................................................................................................................... ..... .. P183
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Primary Open-Angle Glaucoma Suspect Preferred Practice Pattern®
Background:
A diagnosis of primary open-angle glaucoma (POAG) suspect is established by the
presence of consistently elevated intraocular pressure (IOP), also know as ocular
hypertension, or a suspicious optic nerve, retinal nerve fiber layer (RNFL), or visual field
in one or both eyes. Risk factors for POAG include older age, African race or
Latino/Hispanic ethnicity, elevated intraocular pressure (IOP), family history of glaucoma,
lower ocular perfusion pressure, type 2 diabetes mellitus, and thin central cornea.
Rationale for Treatment:

The decision to treat a POAG suspect patient depends on the level of IOP and other
associated risk factors, or evidence of change of the optic nerve, RNFL, or visual field
indicating the development of glaucoma. In the Ocular Hypertension Treatment Study,
more than 90% of patients with untreated ocular hypertension did not progress to glaucoma
over 5 years, but treatment to lower IOP reduced the risk of developing POAG from 9.5%
to 4.5%.
Care Process:
The goals of managing patients who are POAG suspects are to lower IOP with treatment if
the eye is likely to progress to POAG and to monitor for structural or functional changes of
the optic nerve. Appropriate testing to evaluate and monitor POAG suspect patients
includes gonioscopy, pachymetry, tonometry, perimetry, careful examination of the optic
nerve, and imaging of the optic nerve head, RNFL and macula. Patients should be followed
longitudinally for the development of glaucoma. Medical therapy is most commonly used
to lower IOP, but laser trabeculoplasty exists as an alternative to medications for patients
with ocular hypertension.
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OBJECTIVES OF PREFERRED PRACTICE

PATTERN® GUIDELINES
As a service to its members and the public, the American Academy of Ophthalmology has developed a series
of Preferred Practice Pattern® guidelines that identify characteristics and components of quality eye care.
Appendix 1 describes the core criteria of quality eye care.
The Preferred Practice Pattern® guidelines are based on the best available scientific data as interpreted by
panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted
clinical trials are available, the data are particularly persuasive and provide clear guidance. In other instances,
the panels have to rely on their collective judgment and evaluation of available evidence.
These documents provide guidance for the pattern of practice, not for the care of a particular individual.
While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all
patients. Adherence to these PPPs will not ensure a successful outcome in every situation. These practice
patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care
reasonably directed at obtaining the best results. It may be necessary to approach different patients’ needs in
different ways. The physician must make the ultimate judgment about the propriety of the care of a particular
patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology
is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice.
Preferred Practice Pattern® guidelines are not medical standards to be adhered to in all individual
situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind,
from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or
other information contained herein.
References to certain drugs, instruments, and other products are made for illustrative purposes only and are not
intended to constitute an endorsement of such. Such material may include information on applications that are
not considered community standard, that reflect indications not included in approved U.S. Food and Drug
Administration (FDA) labeling, or that are approved for use only in restricted research settings. The FDA has
stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she
wishes to use, and to use them with appropriate patient consent in compliance with applicable law.
Innovation in medicine is essential to ensure the future health of the American public, and the Academy
encourages the development of new diagnostic and therapeutic methods that will improve eye care. It is
essential to recognize that true medical excellence is achieved only when the patients’ needs are the foremost
consideration.
All Preferred Practice Pattern® guidelines are reviewed by their parent panel annually or earlier if
developments warrant and updated accordingly. To ensure that all PPPs are current, each is valid for 5 years
from the “approved by” date unless superseded by a revision. Preferred Practice Pattern guidelines are funded
by the Academy without commercial support. Authors and reviewers of PPPs are volunteers and do not receive
any financial compensation for their contributions to the documents. The PPPs are externally reviewed by
experts and stakeholders, including consumer representatives, before publication. The PPPs are developed in
compliance with the Council of Medical Specialty Societies’ Code for Interactions with Companies. The
Academy has Relationship with Industry Procedures (available at www.aao.org/about-preferred-practice-
patterns) to comply with the Code.
Appendix 2 contains the International Statistical Classification of Diseases and Related Health Problems (ICD)
codes for the disease entities that this PPP covers. Appendix 3 has an algorithm for the management of primary
open-angle glaucoma (POAG) suspect. The intended users of the Primary Open-Angle Glaucoma Suspect PPP
are ophthalmologists.
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METHODS AND KEY TO RATINGS

Preferred Practice Pattern® guidelines should be clinically relevant and specific enough to provide useful
information to practitioners. Where evidence exists to support a recommendation for care, the
recommendation should be given an explicit rating that shows the strength of evidence. To accomplish these
aims, methods from the Scottish Intercollegiate Guideline Network1 (SIGN) and the Grading of
Recommendations Assessment, Development and Evaluation2 (GRADE) group are used. GRADE is a
systematic approach to grading the strength of the total body of evidence that is available to support
recommendations on a specific clinical management issue. Organizations that have adopted GRADE include
SIGN, the World Health Organization, the Agency for Healthcare Research and Policy, and the American
College of Physicians.3
 All studies used to form a recommendation for care are graded for strength of evidence individually, and
that grade is listed with the study citation.
 To rate individual studies, a scale based on SIGN1 is used. The definitions and levels of evidence to rate
individual studies are as follows:
I++ High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or
RCTs with a very low risk of bias
I+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
I- Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
II++ High-quality systematic reviews of case-control or cohort studies
High-quality case-control or cohort studies with a very low risk of confounding or bias and a
high probability that the relationship is causal
II+ Well-conducted case-control or cohort studies with a low risk of confounding or bias and a
moderate probability that the relationship is causal
II- Case-control or cohort studies with a high risk of confounding or bias and a significant risk that
the relationship is not causal
III Nonanalytic studies (e.g., case reports, case series)
 Recommendations for care are formed based on the body of the evidence. The body of evidence quality
ratings are defined by GRADE2 as follows:
Good quality Further research is very unlikely to change our confidence in the estimate of
effect
Moderate quality Further research is likely to have an important impact on our confidence in the
estimate of effect and may change the estimate
Insufficient quality Further research is very likely to have an important impact on our confidence in
the estimate of effect and is likely to change the estimate
Any estimate of effect is very uncertain
 Key recommendations for care are defined by GRADE2 as follows:

Strong Used when the desirable effects of an intervention clearly outweigh the
recommendation undesirable effects or clearly do not
Discretionary Used when the trade-offs are less certain—either because of low-quality evidence
recommendation or because evidence suggests that desirable and undesirable effects are closely
balanced
 The Highlighted Findings and Recommendations for Care section lists points determined by the PPP
Panel to be of particular importance to vision and quality of life outcomes.
 All recommendations for care in this PPP were rated using the system described above. Ratings are
embedded throughout the PPP main text in italics.
 Literature searches to update the PPP were undertaken in March 2019 and June 2020 in the PubMed and
Cochrane databases. Complete details of the literature searches are available in Appendix 4.
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HIGHLIGHTED FINDINGS AND

RECOMMENDATIONS FOR CARE
A diagnosis of primary open-angle glaucoma (POAG) suspect is established by the presence of a consistently
elevated intraocular pressure (IOP), also known as ocular hypertension, or a suspicious optic nerve, retinal
nerve fiber layer (RNFL), or visual field, in one or both eyes.
Established risk factors for POAG include older age, African race or Latino/Hispanic ethnicity, elevated IOP,
family history of glaucoma, low ocular perfusion pressure, type 2 diabetes mellitus, myopia, and a thin
central cornea.
The decision to treat a POAG suspect patient depends on the level of IOP and other associated risk factors, or
evidence of change of the optic nerve, RNFL, or visual field indicating the development of POAG.
In the Ocular Hypertension Treatment Study (OHTS), more than 90% of patients with untreated ocular
hypertension did not progress to glaucoma over 5 years, but treatment to lower IOP reduced the risk of
developing POAG from 9.5% to 4.5%.
A reasonable target for IOP reduction in a POAG suspect patient in whom the decision to treat has been
made is 20%, based on the OHTS.
Appropriate testing to evaluate and monitor patients diagnosed as a glaucoma suspect includes gonioscopy,
pachymetry, tonometry, perimetry, careful examination of the optic nerve, and ocular imaging. Computer-
based imaging and stereoscopic photography provide different and complementary information about optic
nerve status.
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INTRODUCTION
DISEASE DEFINITION
A glaucoma suspect is an individual with clinical findings and/or a constellation of risk factors that
indicate an increased likelihood of developing primary open-angle glaucoma (POAG).
CLINICAL FINDINGS CHARACTERISTIC OF PRIMARY OPEN-ANGLE

GLAUCOMA SUSPECT
An individual with an open anterior chamber angle may be diagnosed as a glaucoma suspect based on
any of the following clinical findings in one or both eyes:
 Elevated intraocular pressure (IOP) associated with normal appearance of the optic disc,
retinal nerve fiber layer (RNFL), and visual field
 An appearance of the optic nerve head (ONH) or RNFL suspicious for glaucomatous damage
 A visual field suspicious for glaucomatous damage in the absence of clinical signs of another
optic neuropathy or retinopathy
This definition excludes the angle-closure glaucomas and known secondary causes for open-angle
glaucoma, such as pseudoexfoliation syndrome, pigment dispersion syndrome, and traumatic angle
recession.
PATIENT POPULATION
The patient population includes adults with open anterior chamber angles with one of the clinical
findings or risk factors listed in the Clinical Findings Characteristic of Primary Open-Angle
Glaucoma Suspect section.
CLINICAL OBJECTIVES
 Identify patients at high risk of developing POAG
 Document the status of the optic nerve structure at presentation by clinical evaluation and imaging,
and document visual function by visual field testing
 Perform and document gonioscopy
 Consider treatment of high-risk individuals to prevent or delay the development of POAG
 Minimize the side effects of treatment and the impact of treatment on the patient’s vision, general
health, and quality of life
 Educate and involve the patient and appropriate family members/caregivers in the management of the
patient’s condition
 Monitor the IOP and the structure and function of the optic nerve for evidence of glaucomatous
damage
BACKGROUND
PREVALENCE
A diagnosis of POAG suspect is established by the presence of at least one of the following
conditions: a consistently elevated IOP, also known as ocular hypertension, or a suspicious optic
nerve or visual field.
Ocular hypertension has been defined as IOP higher than two standard deviations above the mean for
the population without evidence of optic disc or visual field damage.4 In the United States, this
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definition usually includes an IOP greater than 21 mmHg. Using this definition, the prevalence of
ocular hypertension in non-Hispanic whites who are 40 years and older and live in the United States is
4.5% (ranging from 2.7% in persons 43 to 49 years old to 7.7% in those 75 to 79 years old).5 In
Latinos 40 years and older, the overall prevalence is 3.5% (ranging from 1.7% in persons 40 to 49
years old to 7.4% in those 80 years and older).6 There are no published population-based estimates for
the prevalence of ocular hypertension in African Americans and Asian Americans. Overall, 3 to 6
million persons in the United States have ocular hypertension.7, 8
Many studies suggest that a large proportion of people who are glaucoma suspects are likely
undiagnosed. For example, the Los Angeles Latino Eye Study (LALES) showed that 75% of Latinos
with IOP greater than 21 mmHg were previously undiagnosed.6 Because ocular hypertension is a
major risk factor for development of glaucoma, eye care providers should measure IOP in all of their
patients over the age of 40 years. However, the overall likelihood of developing glaucomatous optic
neuropathy may vary among individuals and increases with the number and relative strength of their
risk factors for glaucoma.9
The prevalence of patients diagnosed as glaucoma suspects is less understood because the definition
of glaucoma suspect includes several criteria, including elevated IOP, suspicious visual fields or optic
disc appearance, and RNFL abnormalities, and the criteria for “abnormal” may differ between
clinicians.10, 11 Furthermore, clinicians may consider a patient a glaucoma suspect because of a history
of myopia,12 a background including an ethnoracial group with higher risk of glaucoma,4, 13, 14 or
family history of glaucoma.15
RISK FACTORS
The results of epidemiological studies and clinical trials provide a framework for understanding the
effects of risk factors associated with POAG. Numerous studies have identified risk factors associated
with POAG (see Primary Open-Angle Glaucoma PPP for additional discussion of risk factors):
 Elevated IOP7, 16-26
 Older age16, 17, 20, 21, 27-29
 Family history of glaucoma21, 30
 African race or Latino/Hispanic ethnicity
 Thin central cornea16, 17, 31
 Low systolic and diastolic blood pressure30
 Low ocular perfusion pressure30, 32, 33
 Type 2 diabetes mellitus34-37
 Myopia32, 38-40
 Disc hemorrhage41-45
 Large cup-to-disc ratio16, 17
 High pattern standard deviation on threshold visual field testing17, 26, 46
 Hypothyroidism47
 Male sex48, 49
Although disc hemorrhage, increased cup-disc ratio, and higher pattern standard deviation are
considered to be risk factors for the development of POAG, it can also be argued that these represent
signs of early optic nerve and visual field damage from glaucoma.17, 45, 50
Even though conflicting data exist on the association between type 2 diabetes mellitus and POAG,21,
34-36, 51-56
evidence from population-based studies suggests that type 2 diabetes mellitus is an important
risk factor for POAG.34-36, 52, 54 Population-based assessments of Hispanics (in Los Angeles,
California),35 non-Hispanic whites (in Beaver Dam, Wisconsin, and Blue Mountains, Australia),34, 54
and a large cohort enrolled in the Nurses’ Health Study52 have shown that persons with type 2
diabetes mellitus are more likely (40% higher odds in Hispanics, twofold higher odds in non-Hispanic
whites) to have POAG. Further, longer duration of type 2 diabetes mellitus was associated with a
higher risk of having POAG in the LALES.35 One explanation for this observation is that
microvascular changes in the optic nerve may contribute to the greater susceptibility of optic nerve
damage in persons with type 2 diabetes mellitus.53 Interestingly, authors have suggested that type 2
diabetes is directly associated with a higher IOP reading, likely related to a change in corneal
biomechanics.57 While this may act as a confounder, a recent meta-analysis of 47 studies concluded
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7
that diabetes mellitus is associated with increased risk of glaucoma and may be associated with
elevated IOP.37
Other factors that have been associated with POAG include migraine headache, sleep apnea,
peripheral vasospasm (Raynaud’s syndrome), cardiovascular disease, low corneal hysteresis, and
systemic hypertension.17, 58-65 However, the association between these risk factors and the
development of glaucomatous optic nerve damage has not been demonstrated consistently.17, 28, 32, 38,
66-71
DETECTION
Patients suspected of having POAG can be identified during a comprehensive adult medical eye evaluation.72
Although an assessment of IOP can identify individuals who are ocular hypertensive, an assessment of the
optic nerve structure and function is required to identify patients who are glaucoma suspects but do not have
ocular hypertension.
Medicare provides a benefit for a glaucoma screening for patients with the following risk factors: family
history of glaucoma, history of diabetes, African Americans who are 50 years or older, and Hispanics who
are 65 years or older.
CARE PROCESS
PATIENT OUTCOME CRITERIA

 Preservation of visual function
 Maintenance of quality of life
 Detection of progression to POAG at the earliest possible stage
DIAGNOSIS
The comprehensive initial glaucoma suspect evaluation (history and physical examination) includes
all components of the comprehensive adult medical eye evaluation72 and focuses attention on those
elements that specifically pertain to the diagnosis, course, and treatment of POAG. The evaluation
may require more than one visit. For instance, an individual might be suspected of having POAG on
one visit but may return for further evaluation to confirm the diagnosis, including additional IOP
measurements; gonioscopy; central corneal thickness (CCT) determination; visual field assessment;
and ONH, RNFL, and macula evaluation and documentation.
History
 Ocular history (e.g., refractive error, trauma, prior ocular surgery)
 Race/ethnicity
 Family history.22,73, 74 The severity and outcome of glaucoma in family members, including a
history of visual loss from glaucoma, should be obtained during initial evaluation.73, 74
 Systemic history (e.g., asthma/chronic obstructive pulmonary disease, diabetes, migraine
headache, vasospasm, cardiovascular disease)
 Review of pertinent records, with particular attention to IOP levels and status of the optic nerve
and visual field testing
 Current and prior ocular and nonocular medications (e.g., corticosteroids) and known local or
systemic intolerance to ocular or nonocular medications
Cataract surgery may lower the IOP when compared with the presurgical baseline IOP.75, 76 A
history of laser-assisted in situ keratomileusis (LASIK), small-incision lenticular extraction
(SMILE) or photorefractive keratectomy can be associated with a falsely low IOP measurement
due to thinning of the cornea.77-79
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Evaluation of Visual Function

Self-reported functional status or difficulty with vision can be assessed through patient history.
Patients who are glaucoma suspects are likely to be asymptomatic.
Physical Examination
The ophthalmic evaluation focuses specifically on the following elements in the comprehensive
adult medical eye evaluation:72
 Visual acuity measurement
 Pupil examination
 Confrontation visual fields
 Slit-lamp biomicroscopy
 IOP measurement
 Gonioscopy
 ONH and RNFL examination
 Fundus examination
Visual acuity measurement

The best-corrected visual acuity, at distance and at near, should be determined.
Pupil examination
The pupils are examined for light reactivity and for a relative afferent pupillary defect.80-82
Confrontation visual fields

Confrontation visual fields are evaluated as an adjunct to automated visual field testing.
Slit-lamp biomicroscopy
Slit-lamp biomicroscopic examination of the anterior segment can provide evidence of
physical findings associated with narrow angles, such as shallow peripheral anterior
chamber depth,83, 84 corneal pathology, or a secondary mechanism for elevated IOP.
Secondary mechanisms for elevated IOP can be detected on anterior segment examination
and can include pseudoexfoliation material on the pupil margin, anterior lens capsule, or
corneal endothelium (pseudoexfoliation syndrome); pigment dispersion syndrome with
spoke-like, mid-peripheral radial iris transillumination defects, Scheie stripe, and/or
Krukenberg spindle; iris and angle neovascularization; or inflammation.
Intraocular pressure measurement

Results from the Ocular Hypertension Treatment Study (OHTS) demonstrate that lowering
elevated IOP reduces the risk of developing glaucomatous visual field and optic nerve
damage.16 It is important to evaluate the full extent of IOP fluctuation over time to
determine who is at greatest risk of developing glaucoma and, therefore, who should
receive treatment to prevent future glaucoma. Intraocular pressure is measured in each eye,
preferably by Goldmann applanation tonometry, before gonioscopy or dilation of the
pupil.85 Recording time of day of IOP measurements may be helpful to assess diurnal
variation. The significance of diurnal IOP fluctuation and the development of
glaucomatous damage has yet to be fully established in the literature.86-96 Additional IOP
measurements may be indicated, either at different hours of the day on the same day or on
different days. Larger inter-eye asymmetry of IOP has also been shown to be a risk for
developing glaucoma.97
Gonioscopy
The diagnosis of POAG suspect requires careful evaluation of the anterior chamber angle
to exclude angle closure or secondary causes of IOP elevation, such as angle recession,
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pigment dispersion, peripheral anterior synechiae, angle neovascularization, and

inflammatory precipitates.98 A useful technique to examine a narrow anterior chamber
angle is to have the patient look slightly towards the mirror of the gonioprism into which
the examiner is looking.
(See www.gonioscopy.org for discussion of the techniques of gonioscopy.)
Optic nerve head and retinal nerve fiber layer examination

There is evidence that glaucomatous structural changes detected by optic disc and RNFL
examination may precede functional defects detected by standard automated perimetry
(SAP) in some patients.99-105 In the OHTS, optic nerve damage alone without visual field
loss occurred in 69 eyes and accounted for 55% of the study endpoints reached.16
Examination of the ONH and RNFL provides valuable structural information about
glaucomatous optic nerve damage.101, 103, 106-108 Ocular features that may indicate
glaucomatous optic neuropathy include the following:
 Vertical elongation of the optic nerve cup with an associated decrease in neuroretinal
rim width
 Enlargement of the optic nerve cup
 Diffuse or focal narrowing of the neuroretinal rim, especially superior and/or inferior
 Optic disc hemorrhages involving the disc rim, parapapillary RNFL, or lamina cribrosa
 Nasalization of central ONH vessels
 Baring of the circumlinear vessel
 Absence of pallor in the neuroretinal rim
 Diffuse or focal thinning of the RNFL
 Beta-zone parapapillary atrophy
The size of the physiologic cup is related to the size of the optic disc. Larger overall disc
area is associated with a large optic nerve cup. Commonly, the neuroretinal rim of the optic
nerve is widest inferiorly and narrowest temporally. This anatomic feature is referred to as
ISNT rule: the neuroretinal rim is widest at the inferior rim, followed by the superior rim,
followed by the nasal rim, and lastly by the temporal rim.109-111 In approximately 80% of
patients with glaucomatous cupping, the nerve contour does not follow this rule because
both the inferior and superior rims are thinned.109, 110 However, a recent study has
demonstrated that normal eyes follow the ISNT rule less than 45% of the time.111
Visible structural alterations of the ONH or RNFL and development of parapapillary
choroidal atrophy in early glaucoma may precede the onset of visual field defects.101, 112-114
Other investigations have reported functional deficits occurring in advance of structural
change.115, 116 Careful examination of the optic disc neural rim for small hemorrhages is
important because these hemorrhages sometimes herald focal disc damage and visual field
loss, and they may signify ongoing optic nerve damage in patients with glaucoma.117-130 In
the OHTS, the incidence of POAG in eyes with disc hemorrhage was 13.6% compared
with 5.2% in eyes without disc hemorrhage over 8 years.125 In the Early Manifest
Glaucoma Trial, 13% of patients had disc hemorrhages at baseline examination, and
hemorrhages were associated with progression.118
The optic nerve should be carefully examined for the above signs of glaucomatous damage,
and its appearance should be documented.103, 107, 131 The preferred technique for ONH
evaluation involves magnified stereoscopic visualization (as with the slit-lamp
biomicroscope), preferably through a dilated pupil. In some cases, direct ophthalmoscopy
complements magnified stereoscopic visualization, providing additional information of
optic nerve detail as a result of the greater magnification of the direct ophthalmoscope.
Red-free illumination of the posterior pole may aid in evaluating the RNFL.132 Color
stereophotography is an accepted method for documenting qualitative ONH appearance as
well as disc hemorrhages.45 Computer-based imaging analysis of the ONH and
RNFL/macula is a complementary method for documenting the optic nerve and is
discussed in the Diagnostic Testing section below. Computer-based imaging and
stereoscopic photography of the optic nerve provide different information about optic nerve
status, and both are useful adjuncts to a comprehensive clinical examination.
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Fundus examination
Examination of the fundus through a dilated pupil whenever feasible includes a search for
other abnormalities that may account for optic nerve changes and/or visual field defects
(e.g., optic nerve pallor, disc drusen, optic nerve pits, disc edema, macular degeneration,
retinovascular occlusion, or other retinal disease).
Diagnostic Testing
Important ophthalmic testing includes the following:
 CCT measurement
 Visual field evaluation
 ONH, RNFL, and macular imaging
Central corneal thickness measurement

Measurement of CCT aids the interpretation of IOP readings and helps to stratify patient
risk for ocular damage.17, 31, 133-135 In the OHTS and European Glaucoma Prevention Study
(EGPS) trials, the average CCT in the ocular hypertension group was 570 µm, and the risk
of developing POAG was greater in eyes with corneal thickness less than 555 µm than in
eyes with a corneal thickness of 588 µm or greater. (Additional information is available in
the Central Corneal Thickness section under Risk Factors in the POAG PPP.) An
overestimation of the real IOP as measured by Goldmann applanation tonometry may occur
in eyes with corneas that are thicker than average, whereas an underestimation of the real
IOP tends to occur in eyes with corneas that are thinner than average. An exception to this
is that the measurement of IOP is underestimated in eyes with corneal edema.135 Several
studies have sought to quantify the relationship between measured IOP level and CCT, but
there is no generally accepted correction formula. The World Glaucoma Association
Consensus on IOP suggests that a correction factor should not be used to adjust values
measured in individual patients. Although it is clear that thinner CCT is a risk factor for the
development of POAG,17 studies of progression have had variable findings. Some (but not
all) studies found an association between glaucoma progression and thin CCT (see Table
1).120, 136-141 Corneal hysteresis appears to provide additional, independent information
associated with the risk of POAG.63-65
TABLE 1 SUMMARY OF RESULTS FOR CENTRAL CORNEAL THICKNESS AS A RISK FACTOR FOR PROGRESSION OF GLAUCOMA
Study No. of Level of Risk Comments
Patients Evidence
Early Manifest 255 I + Thin CCT is a risk factor for progression of glaucoma (in
Glaucoma Trial120 patients with baseline IOP ≥21 mmHg)
Kim and Chen136 88 II + Thin CCT is associated with visual field progression in
glaucoma
Chauhan, et al137 54 II - CCT did not predict visual field or optic disc progression
Jonas, et al142 454 II - CCT is not associated with progression of visual field damage
Jonas, et al139 390 II - CCT is not associated with optic disc hemorrhages
Congdon, et al140 230 II - CCT is not associated with glaucoma progression (although
low corneal hysteresis is associated with glaucoma
progression)
Stewart, et al141 310 III +/- CCT is associated with progression on univariate analysis but
is not associated on multivariate analysis
CCT = central corneal thickness

Adapted with permission from Dueker D, Singh K, Lin SC, et al. Corneal thickness measurement in the management of primary open-
angle glaucoma: a report by the American Academy of Ophthalmology. Ophthalmology 2007;114:1784.
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Visual field evaluation

Eye care providers evaluate the visual field using SAP with white-on-white stimuli.143
Testing strategies can be tailored to the patient and degree of visual field loss by using
specific programs that evaluate the central threshold sensitivity at 24 degrees, 30 degrees,
and 10 degrees, and by varying stimulus size. Testing with a 10-2 program may be useful to
detect early visual field damage in the central 10 degrees before such abnormalities are
obvious in a 24- or 30-degree testing strategy.144 Careful manual combined kinetic and
static threshold testing (e.g., Goldmann visual fields) is an acceptable alternative when
patients cannot perform automated perimetry reliably or if it is not available. If visual field
glaucomatous damage is newly detected in a glaucoma suspect patient, it is best to repeat
the testing to confirm the change.145 Repeating the same strategy that showed a new
glaucomatous defect is best for confirming a visual field change.
Frequency doubling technology and short-wavelength automated perimetry (SWAP) are
two alternative testing methods shown to be helpful in screening for early visual field
damage, especially when SAP is normal.143, 146, 147 Frequency doubling technology
measures contrast sensitivity for a frequency doubling stimulus.148-152 Visual field testing
based on SWAP152, 153 isolates short-wavelength sensitive cells using a narrow band of
blue-light stimulus on a yellow background-illuminated perimeter bowl. Despite the
existence of frequency doubling technology and SWAP, all of the major glaucoma clinical
trials used SAP for detection and progression of glaucoma. Clinicians may use these
selective functional tests to diagnose early visual loss in glaucoma suspects, but studies
have not demonstrated clear advantages over standard automated achromatic visual field
testing (e.g., SAP).154-156
Optic nerve head, retinal nerve fiber layer, and macular imaging
The appearance of the optic nerve and RNFL should be documented for the glaucoma
suspect patient, if possible.103, 131 Because they are different methodologies, stereoscopic
disc photographs and computerized images of the nerve are complementary with regard to
the information they provide the clinician.157 In the absence of these methodologies, a
nonstereoscopic photograph or a drawing of the ONH should be recorded, but this is a less
desirable alternative to stereophotography or computer-based imaging.158-161 In some cases,
the topography of the disc is difficult to appreciate on stereo photographs. When the optic
disc is saucerized with a paucity of vessels, the topography is often not easily seen in
photographs, and a disc drawing obtained by using a narrow slit beam of light moving
across the disc may be needed for additional documentation of this anatomic variation.
Computer-based digital imaging of the ONH, RNFL, and macula is routinely used to
provide quantitative information to supplement the clinical examination of the optic
nerve.162 A substantial number of patients demonstrate structural alterations in the ONH
and the macular and parapapillary RNFL before functional change occurs. In many, but not
all, cases computerized imaging may be useful to distinguish between glaucomatous and
nonglaucomatous RNFL thinning, based on the presence or absence of progression,
respectively. 104, 105, 163 There are three types of computer-based optic nerve imaging
devices that have been used to evaluate for glaucoma: confocal scanning laser
ophthalmoscopy, optical coherence tomography (OCT), and scanning laser polarimetry.
The versions of these devices that were studied in a systematic review were similar in their
ability to distinguish glaucomatous eyes from control eyes.103, 162, 164, 165
Abnormal results (i.e., results outside of the normative range) from these devices do not
always represent disease.166 Criteria used to establish normative databases vary between
different imaging devices, and a nerve or RNFL may fall outside normative ranges for
reasons other than glaucoma. Their interpretation should include an evaluation of all
components of the report and not just their summary statistics, after an adequate assessment
of scan quality is performed. Some individual disc findings will not fall into the normative
database that is used to establish abnormality, and results should be interpreted cautiously.
Therefore, results from these tests must be interpreted in the context of the clinical
examination and other supplementary tests in order to avoid falsely concluding that a
statistically abnormal result on imaging represents true abnormality. As these instruments
continue to improve, they may become more reliable in helping the clinician diagnose
12
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glaucoma and to identify progressive nerve damage.104, 105, 163 Furthermore, progression
analysis programs for computer-based imaging devices are evolving to better detect optic
nerve and RNFL changes that may be secondary to glaucoma.167, 168
Because some patients show visual field loss without corresponding optic nerve
progression,16, 99, 167-170 both structural and functional assessments remain integral to patient
care. Even though digital imaging technology is approved as an adjunct to aid in glaucoma
diagnosis, the clinician should include all perimetric and other structural information when
formulating patient management decisions.157 As device technology evolves (e.g., specific
reference databases, higher resolution spectral domain OCT), the performance of
diagnostic imaging devices is expected to improve accordingly.
Differential Diagnosis
Glaucoma is a chronic, progressive optic neuropathy associated with several risk factors,
including IOP, that contribute to damage. The characteristic acquired atrophy of the optic nerve
and loss of retinal ganglion cells and their axons can result in progressive visual field loss.
Other entities associated with optic disc damage or abnormalities of the visual field should be
considered prior to accepting the diagnosis of glaucoma. These nonglaucomatous diseases (and
examples) are categorized as follows:
 Optic disc abnormalities
 Anterior ischemic optic neuropathies
 Optic nerve drusen
 Myopic tilted optic nerves
 Toxic optic neuropathies
 Congenital disc anomalies (e.g., congenital pit, coloboma, periventricular leukomalacia,
morning glory syndrome)
 Leber hereditary optic neuropathy and dominant optic atrophy
 Optic neuritis
 Retinal abnormalities
 Age-related macular degeneration
 Chorioretinal scars from panretinal photocoagulation
 Retinitis pigmentosa
 Retinal arterial and venous occlusions
 Myelinated nerve fibers
 Retinal colobomas
 Central nervous system abnormalities
 Compressive optic neuropathy
 Demyelination from multiple sclerosis
 Nutritional optic neuropathy
MANAGEMENT
Goals
The goals of managing patients with POAG suspect are as follows:
 Monitor or lower IOP through treatment if an eye is likely to progress to POAG
 Monitor for structural changes in the optic disc and retina (RNFL and/or macular analysis)
 Monitor for functional changes of the optic nerve by assessing the visual field
Intraocular pressure is the primary modifiable factor to reduce the risk of conversion to
glaucoma in glaucoma suspects. The decision to begin treatment to lower IOP in the glaucoma
suspect patient is complex and based on the ophthalmologist’s analysis of the examination
results, risk assessment, and the patient’s preferences. The number and severity of risk factors
present, the prognosis, the patient’s life expectancy, management plan, and likelihood that
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therapy, once started, can be continued long-term, should be discussed with the patient and,
when feasible, with the patient’s family. Risk assessment based on the OHTS and EGPS may
be helpful in managing the patient who is a glaucoma suspect.46
In the OHTS, more than 90% of patients with ocular hypertension did not progress to glaucoma
over 5 years, but treatment to lower IOP reduced the risk of developing POAG from 9.5% to
4.5%.16 Since therapy exposes patients to the risks, side effects, and expense of long-term
treatment, the decision to begin treatment for a glaucoma suspect patient is particularly
important. For some patients, the risk of developing POAG is sufficiently high to justify
starting treatment.16, 17, 171 For example, untreated patients in the OHTS with a baseline IOP of
26 mmHg or above and a CCT of 555 µm or below had a 36% chance of developing optic
nerve damage during long-term follow-up compared with a 2% risk for patients with a baseline
IOP of less than 24 mmHg and a CCT greater than 588 µm.17 Whether or not a patient is
treated, long-term monitoring for the development of glaucoma is essential.
When treatment is appropriate, an effective medication regimen requires attention to its effect
on IOP, side effects, and to the possibility of nonadherence to therapy. Laser trabeculoplasty
can also be considered as primary therapy for ocular hypertension. The ophthalmologist should
consider these issues in choosing a regimen that works well to lower IOP to the desired level
with the fewest possible side effects. The diagnosis, number and severity of risk factors,
prognosis and management plan, and likelihood of long-term therapy should be discussed with
the patient.
Deciding When to Treat a Glaucoma Suspect Patient

The decision to treat a glaucoma suspect patient may arise in various settings.
 Any patient who shows evidence of optic nerve deterioration based on ONH appearance, RNFL
loss, or visual field changes consistent with glaucomatous damage has developed POAG and
should be offered treatment as described in the Primary Open-Angle Glaucoma PPP.172
Clinicians can recognize subtle abnormalities in the optic disc and RNFL by using periodic
fundus imaging with disc photography and computerized imaging of the ONH, RNFL, and
macula.101, 173
 A new visual field defect that is consistent with a pattern of glaucomatous visual field defect,
confirmed on retesting of visual fields, may indicate that the patient has developed POAG.145, 174
Strategies include Goldmann visual field testing, 30-2 and 24-2 testing, and central 10-2 testing.
Automated 10-2 central visual field testing has demonstrated the ability to discern central
defects that can be missed with wider field perimetry.144
 A patient who demonstrates very high IOP in which optic nerve damage is likely to occur may
require treatment.
 In some cases, initiating IOP-lowering treatment to lower the risk of glaucomatous damage may
be appropriate if the patient has additional risk factors for glaucoma. Established risk factors for
POAG, besides elevated IOP, include older age, family history of glaucoma, African-derived
race or Latino/Hispanic ethnicity, thin central cornea, low ocular perfusion pressure, diabetes
mellitus, myopia, low systolic and diastolic blood pressure, disc hemorrhage, large cup-to-disc
ratio, high pattern standard deviation on threshold visual field testing, hypothyroidism, and male
sex.
 Clinicians may consider using a risk calculator to determine the risk of progressing from ocular
hypertension to POAG.46, 175-177 These calculators determine the overall risk of developing
glaucoma in 5 years using the risk factors of age, vertical cup-to-disc ratio, pattern standard
deviation (from standard automated achromatic visual field testing), CCT, and IOP. Risk
calculators are available on https://ohts.wustl.edu/risk/. They are also available as applications
for smartphones.
Whatever the scenario, a discussion must occur between the physician and patient to outline the
risks and benefits of treatment versus observation.
Target Intraocular Pressure

When deciding to treat a glaucoma suspect patient, it is important to remember that the goal of
treatment is to maintain the IOP in a range at which visual field loss is unlikely to significantly
affect a patient’s health-related quality of life over his or her lifetime.178 The estimated upper
limit of this range is considered the “target pressure.” Target pressure can vary among these
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patients, and in the same patient it may need adjustment during the clinical course. In any
patient, target pressure is an estimate and a means toward the ultimate goal of protecting the
patient’s vision. For a patient in whom a decision has been made to begin treatment, a
reasonable target IOP based on the OHTS would be 20% lower than the mean of several
baseline IOP measurements.16 However, if the starting pressure is markedly elevated, a 20%
reduction may be insufficient to prevent or adequately slow conversion to glaucoma. Current
IOP and its relationship to target IOP should be evaluated at each visit and individualized for
each patient.
A definite deterioration in optic nerve structure or visual field (i.e., conversion to POAG) in a
patient who was a glaucoma suspect suggests that the target pressure should be lower,118, 179 and
the patient should be managed as described in the Primary Open-Angle Glaucoma PPP.172
Choice of Therapy
When the decision is made to treat the POAG suspect patient, the clinician can weigh the risks
and benefits of each treatment modality.
Medical Treatment
Medical therapy is presently the most common initial intervention to lower IOP (see Table
2 for an overview of options available). Prostaglandin analogs are the most frequently
prescribed eye drops for lowering IOP because they are the most efficacious and well-
tolerated glaucoma medication, and they need to be instilled only once daily.180, 181
Therefore, prostaglandin analogues are often considered as initial medical therapy unless
other considerations such as contraindications, cost, side effects, intolerance, or patient
refusal preclude this.182, 183
Topical beta adrenergic antagonists are commonly prescribed to treat glaucoma and have
demonstrated good efficacy and tolerability.184 Nonselective beta adrenergic antagonists
(e.g., timolol) block both beta-1 (primarily cardiac) and beta-2 (primarily pulmonary)
receptors. Cardioselective beta-blockers (e.g. betaxolol) target beta-1 receptors and
minimize, but do not completely eliminate, the risk of pulmonary adverse effects in
patients with obstructive airway disease.185 Topical beta-blockers may be dosed once or
twice daily. However, nighttime dosing of beta-blockers is associated with limited
efficacy186 and may contribute to visual field progression via nocturnal reduction of
systemic blood pressure.187 Other glaucoma medications include, alpha2 adrenergic
agonists, topical and oral carbonic anhydrase inhibitors, rho kinase inhibitors and
parasympathomimetics.188, 189
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TABLE 2 GLAUCOMA MEDICATIONS

Drug Agents Methods of IOP Potential Potential FDA Pregnancy
Classification Action Reduction* Side Effects Contraindications Safety
Category†
Prostaglandin Bimatoprost Increase uveoscleral 25%–33% • Increased and misdirected • Macular edema C
analogs‡ Latanoprost and/or trabecular eyelash growth • History of herpetic
outflow • Periocular hyperpigmentation keratitis
Latanoprostene
• Conjunctival injection • Active uveitis
bunod
• Allergic conjunctivitis/contact
Tafluprost dermatitis
Travoprost • Keratitis
• Possible herpes virus
activation
• Increased iris pigmentation
• Uveitis
• Cystoid macular edema
• Periorbitopathy
• Migraine-like headache
• Flu-like symptoms
Beta-adrenergic Nonselective Decrease aqueous 20%–25% • Allergic conjunctivitis/contact • Chronic obstructive C
antagonists Carteolol production dermatitis pulmonary disease
(beta-blockers) • Keratitis • Asthma
Levobunolol
• Bronchospasm • CHF
Metipranolol
• Bradycardia • Bradycardia
Timolol
• Hypotension • Hypotension
Selective • CHF • Greater than first-
Betaxolol • Reduced exercise tolerance degree heart block
• Depression
• Impotence
Alpha-adrenergic Apraclonidine Decrease aqueous 20%–25% • Allergic conjunctivitis/contact • Monoamine B
agonists Brimonidine production; decrease dermatitis oxidase inhibitor
episcleral venous • Follicular conjunctivitis therapy
pressure or increase • Dry mouth and nose • Infants and children
uveoscleral outflow
• Hypotension
• Headache
• Fatigue
• Somnolence
Parasympathomi- Cholinergic agonist Increase trabecular 20%–25% • Increased myopia • Areas of peripheral C
metic agents Pilocarpine outflow • Decreased vision retina that
• Cataract predispose to
Anticholinesterase
breaks
agent • Periocular contact dermatitis
• Allergic conjunctivitis/contact • The need to
Echothiophate
dermatitis regularly assess the
• Conjunctival scarring fundus
• Conjunctival shrinkage • Neovascular,
uveitic, or malignant
• Keratitis glaucoma
• Paradoxical angle closure
• Retinal tears/detachment
• Eye or brow ache/pain
• Increased salivation
• Abdominal cramps
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TABLE 2 GLAUCOMA MEDICATIONS (CONTINUED)

Drug Agents Methods of IOP Potential Potential FDA Pregnancy
Classification Action Reduction* Side Effects Contraindications Safety
Category†
Rho kinase inhibitors Netarsudil Increase trabecular 10%–20% • Conjunctival hyperemia • None --**
outflow • Corneal verticillata
Decrease episcleral
• Instillation site pain
venous pressure
• Conjunctival hemorrhage
Decrease aqueous
production • Keratitis
Topical carbonic Brinzolamide Decrease aqueous 15%–20% • Allergic dermatitis/conjunctivitis • Sulfonamide allergy C
anhydrase inhibitors Dorzolamide production • Corneal edema • Sickle cell disease
• Keratitis with hyphema
• Metallic taste
Oral carbonic Acetazolamide Decrease aqueous 20%–30% • Stevens-Johnson syndrome • Sulfonamide allergy C
anhydrase inhibitors Methazolamide production • Malaise, anorexia, depression • Kidney stones
• Serum electrolyte imbalance • Aplastic anemia
• Renal calculi • Thrombocytopenia
• Blood dyscrasias (aplastic • Sickle cell disease
anemia, thrombocytopenia)
• Metallic taste
• Enuresis
• Parasthesia
• Diarrhea
• Abdominal cramps
CHF = congestive heart failure; FDA = Food and Drug Administration; IOP = intraocular pressure
* Data from the Heijl A, Traverso CE, eds. Terminology and Guidelines for Glaucoma. European Glaucoma Society. 4th ed. Savona,
Italy: PubliComm; 2014:146-51. Available at: http://www.icoph.org/dynamic/attachments/resources/egs_guidelines_4_english.pdf
Accessed October 16, 2020.
† FDA Pregnancy Category B = Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate
and well-controlled studies on pregnant women. FDA Pregnancy Category C = Animal reproduction studies have shown an adverse
effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug
in pregnant women despite potential risks.
‡ Latanoprostene bunod is rapidly metabolized to latanoprost (a prostaglandin analogue) and butanediol mononitrate (a nitric oxide-
donating moiety); it enhances aqueous outflow through both the uveoscleral and trabecular meshwork pathways.190-193
** The FDA replaced the ABCDX drug pregnancy categories with descriptive information on medication risks to the developing fetus,
breastfed infant, and individual of reproductive potential under the Pregnancy and Lactation Labeling Rule in 2015. Rho kinase
inhibitors are therefore not assigned a pregnancy category. No data exist regarding the use of netarsudil in pregnant women. Animal
studies did not demonstrate adverse effects on the developing fetus with clinically relevant intravenous exposures.194
To determine the effectiveness of topical therapy, it is necessary to distinguish between the

therapeutic impact of an agent on IOP and ordinary background spontaneous fluctuations of
IOP. Though the monocular trial has been recommended in the past to determine whether a glaucoma
medication is effective, studies have shown that it is not a good predictor of long-term efficacy.195, 196
A monocular trial is defined as the initiation of treatment in only one eye, followed by a comparison
of the relative change of the IOP in both eyes at follow-up visits to account for spontaneous
fluctuations in IOP. However, the trial may not work because the two eyes of an individual may
respond differently to the same medication, asymmetric spontaneous fluctuations in IOP may
occur, and monocular topical medications may have a contralateral effect.197 A better way to
assess IOP-lowering response is to compare the effect in one eye with multiple baseline
measurements in the same eye, but the number of necessary baseline measurements will vary
among patients.198
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If a drug fails to reduce IOP sufficiently, then either switching to an alternative medication as
monotherapy or adding additional medication is appropriate until the desired IOP level is
attained.131 Since some studies have shown that adding a second medication decreased
adherence to glaucoma treatment,199, 200 fixed combination therapy may improve patient
adherence even though it is not recommended for initial treatment in most circumstances.
The patient and the ophthalmologist together decide on a practical and feasible regimen to
follow in terms of dosing, cost, and adherence in the context of the patient’s age and
preferences.131 The ophthalmologist should assess the patient for local ocular and systemic side
effects and toxicity, including interactions with other medications and potential life-threatening
adverse reactions. Patients can be educated about eyelid closure or nasolacrimal occlusion to
reduce systemic absorption after medication instillation (see Related Academy Materials
section for patient education brochures).201
Adequate treatment to lower IOP requires a high level of adherence to therapy, but this is
frequently not achieved. Several studies indicate relatively poor adherence to therapy.202-205
Even with instruction, free medication, once-daily administration, use of a dosing aid, and
electronic monitoring of adherence, nearly 45% of patients with glaucoma in one study took
fewer than 75% of their prescribed doses.205 Fixed combinations of two medications may
improve patient adherence by reducing the number of drops required for therapy. Instilling eye
drops correctly is difficult for many patients, and their ability to do so may worsen with aging
and comorbidities and as glaucoma progresses.206, 207 Repeated instruction and counseling about
proper techniques for using medication as well as a clearly written medication regimen,
smartphone reminders, and follow-up telephone calls may improve adherence to therapy.205, 208
A Cochrane Systematic Review in 2013 found that although complex interventions consisting
of patient education combined with personalized behavioral change interventions, including
tailoring daily routines to promote adherence to eye drops, may improve adherence to glaucoma
medication, overall there is insufficient evidence to recommend a particular intervention.
Simplified drug regimens also could be of benefit but again the current published studies do not
provide conclusive evidence. Thus, adherence interventions are left to the judgment of the
treating ophthalmologist.209 (I-, Insufficient Quality, Strong Recommendation) At each
examination, medication dosage and frequency of use should be recorded. Reviewing the time
of day when medication was taken may link eye-drop administration to activities of daily living
and help to ensure patients are actually using their eye drops. Adherence to the therapeutic
regimen and recommendations for therapeutic alternatives, such as laser trabeculoplasty, should
be discussed. Cost may be a factor in adherence, especially when multiple medications are
used.208, 210
Patient education and informed participation in treatment decisions may improve adherence208
and overall effectiveness of management. Adherence to medical therapy may be handicapped
when patients run out of medication, due to inadvertent drop wastage or inability to properly
instill eye drops, before they are permitted to refill their prescription. One study found this was
more likely for patients who self-administered eye drop medications when visual acuity was
worse than 20/70 in either eye.211 However, patients with Medicare insurance may now refill
their medication after they have completed at least 70% of the month, or approximately 21 days
of therapy.212
Multiple drug delivery systems have been developed to address the problems of patient
adherence and side effects associated with glaucoma medical therapy. Enhanced drug delivery
targets include punctal plugs,213 rings placed in the fornix,214 contact lenses,215 subconjunctival
injections216/devices,217 intracameral delivery systems,218 and drug-eluting intraocular
devices.219 In 2020, a bimatoprost intracameral implant (Allergan, Irvine, CA) received Food
and Drug Administration (FDA) approval for use in patients with ocular hypertension and
POAG. This biodegradable implant, which is injected with a 28-gauge delivery system,
demonstrated noninferiority to twice daily timolol in phase III clinical trials.220 In phase I/II
studies, a single bimatoprost sustained-release (SR) implant showed efficacy similar to topical
bimatoprost 0.03% through 4 months of follow-up, and 68% of patients had a persistent effect
at 6 months.218
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Special circumstances in pregnancy and during breastfeeding

Managing IOP in the pregnant or lactating patient involves an interdisciplinary approach to
balance the risk of disease progression in the mother while minimizing risks to the fetus or
nursing infant.
Pregnancy
Glaucoma medical management of the pregnant patient presents challenges with respect to
balancing the risk of glaucomatous progression221 against concerns for the safety of the
fetus.222-224 Data on the risks of topical ocular hypotensive agents during pregnancy are
limited. The FDA established drug pregnancy categories of A, B, C, D, and X in 1979.225
Pregnancy Category A indicates evidence from studies in pregnant women that the drug
failed to show fetal risk, in any trimester. Category B indicates animal reproductive studies
failed to show fetal risk, and that there are no well-controlled studies in pregnant women.
Category C indicates that animal reproductive studies showed adverse effects on the fetus
and that there are no well-controlled studies on pregnant women. Category D indicates
evidence of human fetal risk. Category X indicates that animal and human studies showed
fetal abnormalities. Brimonidine has a Pregnancy Category B rating. Beta-blockers,
prostaglandin analogs, carbonic anhydrase inhibitors, parasympathomimetics, and
hyperosmotics have a Pregnancy Category C rating. Beta-blockers tend to be used during
pregnancy because there is long-term experience with this drug class. A paucity of data
exists on the risk of taking latanoprost in pregnancy, although a small case series of 11
subjects who took this agent while pregnant revealed no adverse effects on pregnancy and
no birth defects.226 In general, most ophthalmologists avoid the use of prostaglandins
during pregnancy because of the theoretical risk of premature labor, but these medications
may be considered for use in the breastfeeding mother.224 Oral carbonic anhydrase
inhibitors have been shown to cause teratogenicity when delivered in high doses to
animals.227
The FDA replaced the ABCDX drug pregnancy categories with descriptive information on
medication risks to the developing fetus, breastfed infant, and individual of reproductive
potential under the Pregnancy and Lactation Labeling Rule in 2015. Rho kinase inhibitors
are therefore not assigned a pregnancy category. No data exist on the use of netarsudil in
pregnant women. Animal studies did not demonstrate adverse effects on the developing
fetus with clinically relevant intravenous exposures.194
Breastfeeding
Some topical glaucoma medications have been detected in breast milk, such as timolol,
carbonic anhydrase inhibitors, and brimonidine. The data are controversial as to whether
timolol poses a threat to the breastfeeding infant. The American Academy of Pediatrics has
approved the use of both oral and topical forms of carbonic anhydrase inhibitors during
lactation, although the infant should be carefully monitored when the former are used.224, 228
Brimonidine is known to cross the blood-brain barrier and can cause apnea and somnolence
in infants, toddlers, and children. For this reason, it is generally recommended that the
medication not be used in mothers who are breastfeeding.223
Other Therapies
Laser trabeculoplasty is an alternative therapy to medications in patients with ocular
hypertension.229 In the Selective Laser Trabeculoplasty Versus Eye Drops for the First-line
Treatment of Ocular Hypertension and Glaucoma (LiGHT) trial, patients randomized to
laser treatment were more likely to be at or below their target pressure than those
randomized to topical therapy.
Cataract surgery in patients with ocular hypertension has also been shown to produce
sustained pressure-lowering effects.76 If incisional glaucoma surgery is to be considered for
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markedly elevated IOP, the patient can be managed as described in the Primary Open-
Angle Glaucoma PPP.172
Follow-up Evaluation
The purpose of follow-up examination is to evaluate the IOP level, visual field status, optic disc
appearance, and retinal imaging (RNFL and/or macula analysis) status to determine if damage
has occurred. Management for each patient should be individualized. Primary open-angle
glaucoma suspect patients who are being observed should be seen at least every 12 to 24
months, depending on individual risk factors. However, if a patient has multiple risk factors for
conversion to POAG, then more-frequent reassessment is justified. If patients have central
vision complaints or if the clinician’s index of suspicion is high for central visual field defects,
central visual field testing can be done to assess the central vision with greater precision.
Primary open-angle glaucoma suspect patients who are being treated may need to be seen more
often until IOP control has been achieved, and then they may be followed semiannually or
annually.
History
The following interval history should be elicited during all follow-up visits for POAG
suspect patients:
 Interval ocular history
 Interval systemic medical and medication history
 Side effects of ocular medications if the patient is being treated
 Review of pertinent medication use if the patient is being treated, including the time of
the last administration
Ophthalmic examination
The following components of the ophthalmic examination should be performed during all
follow-up visits for POAG suspect patients:
 Visual acuity measurement
 Slit-lamp biomicroscopy
 IOP measurement
The frequency of periodic ONH evaluation and documentation,158, 230-232 structural optic
nerve and retina assessments, and visual field evaluation233-235 is based on an assessment of
each patient’s individual risk. A comprehensive adult medical eye evaluation and
additional eye assessments can be performed on follow-up examination,72 with more
frequent follow-up if the patient is at higher risk for developing glaucoma. Patients with a
thin cornea,16, 17, 31 elevated IOP,7, 16-26 disc hemorrhage,41-45, 236 large cup-to-disc ratio,16, 17
high pattern standard deviation,17, 26, 46 development of pseudoexfoliation or pigment
dispersion syndrome, or family history of glaucoma21, 237 may warrant closer follow-up
than patients without these risk factors. Gonioscopy is indicated when there is a suspicion
of development of an angle-closure component, anterior chamber shallowing, anterior
chamber angle abnormalities, or if there is an unexplained change in IOP.
Adjustment of therapy
The indications for adjusting therapy in glaucoma suspect patients are as follows:
 Target IOP is not achieved and the benefits of a change in therapy outweigh the risks
for the patient
 The patient is intolerant of the prescribed medical regimen
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 The patient does not adhere to the prescribed medical regimen due to costs or other
factors
 New systemic conditions or treatments develop that could be a contraindication to the
current glaucoma therapy
 The patient under treatment has been stable for a prolonged period without progression
to POAG, in which case cautious withdrawal of therapy may be considered
 The patient has converted to POAG (see Primary Open-Angle Glaucoma PPP)
PROVIDER AND SETTING

The performance of certain diagnostic procedures (e.g., tonometry, pachymetry, perimetry, fundus
imaging, and photography) may be delegated to appropriately trained and supervised personnel.
However, the interpretations of results and the medical management of disease require the medical
training, clinical judgment, and the experience of an ophthalmologist.
COUNSELING AND REFERRAL

It is important to educate and engage patients in the management of their condition by providing in-
person and written take-home and online information. This may be especially true for patients who
are POAG suspects, since some authors have shown that follow-up is poor in patients with this
diagnosis.238, 239 One reason for this may relate to patients’ perception that their disease is “not serious
enough.”238 Patients should be educated about their condition and its potential to lead to glaucoma, the
status of their condition, the rationale and goals of any intervention, and the relative benefits and risks
of alternative interventions so that they can participate meaningfully in developing an appropriate plan
of action. Patients should be encouraged to alert their ophthalmologist to physical or emotional
changes that occur when taking glaucoma medications. Ophthalmologists should be sensitive to these
problems and provide support and encouragement. Ophthalmologists, or trained staff members,
should educate patients and/or their caregivers on techniques for administering glaucoma drops.
Patients considering keratorefractive surgery should be informed about the possible impact laser
vision correction has on reducing contrast sensitivity and decreasing the accuracy of IOP
measurements.79
SOCIOECONOMIC CONSIDERATIONS
Although there is strong evidence that medical treatment of patients with definite open-angle
glaucoma is cost-effective, it is less clear whether it is cost-effective to treat glaucoma suspects.
Results from the OHTS clearly demonstrate that lowering IOP reduces the risk of progressing to
glaucoma, yet the majority of patients in both the treated and untreated study arms never went on to
develop glaucoma. Therefore, the additional costs of treating all of these patients need to be carefully
considered relative to the benefits conferred by delaying or preventing glaucoma for a small subset of
patients. Based on findings from the OHTS, researchers studied the incremental cost-effectiveness of
treating patients with ocular hypertension and determined that it was not considered cost-effective to
treat all patients with this condition. However, they determined that treatment of patients with ocular
hypertension who have an IOP of 24 mmHg or higher and a 2% or higher annual risk of developing
glaucoma was indeed cost-effective.210 These researchers also showed that patient life expectancy is
an important consideration. For example, a 45-year old with ocular hypertension and a 2% or higher
annual risk of glaucoma would require a life expectancy of at least 18 years for treatment to be
considered cost-effective. Patients who are older at the time of first diagnosis of ocular hypertension
would have to live even longer for treatment to be considered cost-effective.240 Other authors
performed a similar set of analyses and also concluded that treatment of all patients with ocular
hypertension did not confer high value. However, treatment of persons with ocular hypertension who
had risk factors for progressing to glaucoma (e.g., higher levels of IOP, thinner corneas, and greater
cup-to-disc ratios) was indeed cost-effective.241
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Another important question is whether it is cost-effective to screen patients for glaucoma. A

systematic review of the literature on this topic concluded that screening an entire population for
glaucoma is not cost-effective, but targeted screening of high-risk groups may be.242 Medicare
provides benefits for screening high-risk groups such as African Americans, Hispanics, persons with a
family history of glaucoma, and those with diabetes.243 As the sensitivity, specificity, efficiency, and
safety of equipment used to properly diagnose patients with glaucoma continue to improve, it is hoped
that there will soon be ways to perform screenings of large numbers of patients for glaucoma in a
manner that is cost-effective.
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APPENDIX 1. QUALITY OF OPHTHALMIC

CARE CORE CRITERIA
Providing quality care
is the physician's foremost ethical obligation, and is
the basis of public trust in physicians.
AMA Board of Trustees, 1986
Quality ophthalmic care is provided in a manner and with the skill that is consistent with the best interests of
the patient. The discussion that follows characterizes the core elements of such care.
The ophthalmologist is first and foremost a physician. As such, the ophthalmologist demonstrates
compassion and concern for the individual, and utilizes the science and art of medicine to help alleviate
patient fear and suffering. The ophthalmologist strives to develop and maintain clinical skills at the highest
feasible level, consistent with the needs of patients, through training and continuing education. The
ophthalmologist evaluates those skills and medical knowledge in relation to the needs of the patient and
responds accordingly. The ophthalmologist also ensures that needy patients receive necessary care directly or
through referral to appropriate persons and facilities that will provide such care, and he or she supports
activities that promote health and prevent disease and disability.
The ophthalmologist recognizes that disease places patients in a disadvantaged, dependent state. The
ophthalmologist respects the dignity and integrity of his or her patients and does not exploit their
vulnerability.
Quality ophthalmic care has the following optimal attributes, among others.
 The essence of quality care is a meaningful partnership relationship between patient and physician. The
ophthalmologist strives to communicate effectively with his or her patients, listening carefully to their
needs and concerns. In turn, the ophthalmologist educates his or her patients about the nature and
prognosis of their condition and about proper and appropriate therapeutic modalities. This is to ensure
their meaningful participation (appropriate to their unique physical, intellectual, and emotional state) in
decisions affecting their management and care, to improve their motivation and compliance with the
agreed plan of treatment, and to help alleviate their fears and concerns.
 The ophthalmologist uses his or her best judgment in choosing and timing appropriate diagnostic and
therapeutic modalities as well as the frequency of evaluation and follow-up, with due regard to the
urgency and nature of the patient's condition and unique needs and desires.
 The ophthalmologist carries out only those procedures for which he or she is adequately trained,
experienced, and competent, or, when necessary, is assisted by someone who is, depending on the
urgency of the problem and availability and accessibility of alternative providers.
 Patients are assured access to, and continuity of, needed and appropriate ophthalmic care, which can be
described as follows.
 The ophthalmologist treats patients with due regard to timeliness, appropriateness, and his or her own
ability to provide such care.
 The operating ophthalmologist makes adequate provision for appropriate pre- and postoperative
patient care.
 When the ophthalmologist is unavailable for his or her patient, he or she provides appropriate alternate
ophthalmic care, with adequate mechanisms for informing patients of the existence of such care and
procedures for obtaining it.
 The ophthalmologist refers patients to other ophthalmologists and eye care providers based on the
timeliness and appropriateness of such referral, the patient's needs, the competence and qualifications
of the person to whom the referral is made, and access and availability.
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 The ophthalmologist seeks appropriate consultation with due regard to the nature of the ocular or other
medical or surgical problem. Consultants are suggested for their skill, competence, and accessibility.
They receive as complete and accurate an accounting of the problem as necessary to provide efficient
and effective advice or intervention, and in turn they respond in an adequate and timely manner. The
ophthalmologist maintains complete and accurate medical records.
 On appropriate request, the ophthalmologist provides a full and accurate rendering of the patient's
records in his or her possession.
 The ophthalmologist reviews the results of consultations and laboratory tests in a timely and effective
manner and takes appropriate actions.
 The ophthalmologist and those who assist in providing care identify themselves and their profession.
 For patients whose conditions fail to respond to treatment and for whom further treatment is
unavailable, the ophthalmologist provides proper professional support, counseling, rehabilitative and
social services, and referral as appropriate and accessible.
 Prior to therapeutic or invasive diagnostic procedures, the ophthalmologist becomes appropriately
conversant with the patient's condition by collecting pertinent historical information and performing
relevant preoperative examinations. Additionally, he or she enables the patient to reach a fully informed
decision by providing an accurate and truthful explanation of the diagnosis; the nature, purpose, risks,
benefits, and probability of success of the proposed treatment and of alternative treatment; and the risks
and benefits of no treatment.
 The ophthalmologist adopts new technology (e.g., drugs, devices, surgical techniques) in judicious
fashion, appropriate to the cost and potential benefit relative to existing alternatives and to its
demonstrated safety and efficacy.
 The ophthalmologist enhances the quality of care he or she provides by periodically reviewing and
assessing his or her personal performance in relation to established standards, and by revising or altering
his or her practices and techniques appropriately.
 The ophthalmologist improves ophthalmic care by communicating to colleagues, through appropriate
professional channels, knowledge gained through clinical research and practice. This includes alerting
colleagues of instances of unusual or unexpected rates of complications and problems related to new
drugs, devices, or procedures.
 The ophthalmologist provides care in suitably staffed and equipped facilities adequate to deal with
potential ocular and systemic complications requiring immediate attention.
 The ophthalmologist also provides ophthalmic care in a manner that is cost effective without
unacceptably compromising accepted standards of quality.
Reviewed by: Council

Approved by: Board of Trustees
October 12, 1988
2nd Printing: January 1991
3rd Printing: August 2001
4th Printing: July 2005
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24
APPENDIX 2. INTERNATIONAL
STATISTICAL CLASSIFICATION OF
DISEASES AND RELATED HEALTH
Primary open-angle glaucoma suspect includes the entity of primary open-angle suspect or borderline
glaucoma and related entities with the following ICD-10 classifications:
ICD-10 CM
Primary open-angle glaucoma suspect H40.001
H40.002
H40.003
Preglaucoma, unspecified H40.001
H40.002
H40.003
Open angle with borderline findings, low risk H40.011
(e.g., borderline IOP or optic disc appearance
H40.012
suspicious of glaucoma)
H40.013
1–2 risk factors*
Steroid responders H40.041
H40.042
H40.043
Ocular hypertension H40.051
H40.052
H40.053
Open angle with borderline findings, high risk H40.021
3 or more risk factors* H40.022
H40.023
CM = Clinical Modification used in the United States; IOP = intraocular pressure
* Risk factors include family history of glaucoma, higher IOP, thinner central cornea, disc hemorrhage, larger cup-to-disc ratio, pigment
dispersion syndrome, and pseudoexfoliation.
Additional information for ICD-10 codes:

• Certain ICD-10 CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the
category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a
code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters.
• For bilateral sites, the final character of the codes in the ICD-10 CM indicates laterality. If no bilateral code is provided and the
condition is bilateral, separate codes for both the left and right side should be assigned. Unspecified codes should be used only
when there is no other code option available.
• When the diagnosis code specifies laterality, regardless of which digit it is found in (i.e., 4th digit, 5th digit, or 6th digit):
• Right is always 1
• Left is always 2
• Bilateral is always 3
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APPENDIX 3. MANAGEMENT ALGORITHM FOR

PATIENTS WITH PRIMARY OPEN-ANGLE
GLAUCOMA SUSPECT
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26
APPENDIX 4. LITERATURE SEARCHES FOR

THIS PPP
Literature searches of the PubMed and Cochrane databases were conducted in March 2019; the search
strategies were as follows. Specific limited update searches were conducted after June 2020.
("Glaucoma"[Mesh] OR "Ocular Hypertension"[Mesh] OR “poag suspect”) AND ("Optic Atrophy"[Mesh]

OR "Optic Nerve"[Mesh] OR "Optic Nerve Diseases"[Mesh] OR "Optic Disk"[Mesh] OR "Nerve
Fibers"[Mesh] OR "retinal nerve fiber layer")
("Glaucoma"[Mesh] OR glaucoma OR "Ocular Hypertension"[Mesh] OR "Intraocular Pressure"[Mesh] OR

“poag suspect”) AND ("corneal thickness" OR CCT OR "Cornea/pathology"[Mesh])
("Glaucoma"[Mesh] OR glaucoma OR "Ocular Hypertension"[Mesh] OR "Intraocular Pressure"[Mesh] OR

“poag suspect”) AND pachymetry
("Circadian Rhythm"[Mesh] OR "circadian rhythm" OR diurnal OR nocturnal) AND ("Intraocular

Pressure"[Mesh] OR "intraocular pressure" OR IOP)
(("Glaucoma, Open-Angle"[Mesh] AND suspect*) OR (POAG AND Suspect*) OR “poag suspect” OR

(glaucoma AND suspect*))
RELATED ACADEMY MATERIALS
Basic and Clinical Science Course Glaucoma (Section 10, 2019–2020)
Ophthalmic Technology Assessment – Free downloads available at

www.aaojournal.org/content/OphthalmicTechnologyAssessment.
Swept-Source OCT for Evaluating the Lamina Cribrosa OTA (2019)
The Effect of Anti-Vascular Endothelial Growth Factor Agents on Intraocular Pressure and Glaucoma OTA
(2019)
Spectral-Domain OCT: Helping the Clinician Diagnose Glaucoma OTA (2018)
Laser Peripheral Iridotomy in Primary Angle Closure OTA (2018)
Disinfection of Tonometers OTA (2017)
The Effect of Phacoemulsification on Intraocular Pressure in Glaucoma Patients OTA (2015)
Patient Education
Glaucoma Brochure (2020) (also available in Spanish)
Glaucoma Patient Education Video Collection (2015)
Laser Iridotomy Brochure (2019)
Eye Drops Brochure (2019)
Glaucoma Drainage Implant Brochure (2019)
Laser Iridotomy Brochure (2019)
Laser Trabeculoplasty Brochure (2019)
Trabeculectomy Brochure (2020)
Preferred Practice Pattern® Guidelines – Free downloads available at www.aao.org/ppp.

Comprehensive Adult Medical Eye Evaluation (2020)
Primary Open-Angle Glaucoma (2020)
Vision Rehabilitation for Adults (2017)
Focal Points
Optical Coherence Tomography in Glaucoma Diagnosis (2017)
Update on Pseudoexfoliative Glaucoma (2019)
Surgical Management of Angle Closure Glaucoma (2018)
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Clinical Applications of Major Glaucoma Trials (2018)

Microinvasive Glaucoma Surgery and Cataract Surgery Synergy (2018)
To order any of these products, except for the free materials, please contact the Academy’s Customer Service
at 866.561.8558 (U.S. only) or 415.561.8540 or www.aao.org/store.
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Primary Open-Angle

Medical Editor: Susan Garratt

Approved by: Board of Trustees

Copyright © 2020 American Academy of Ophthalmology®

AMERICAN ACADEMY OF OPHTHALMOLOGY and PREFERRED PRACTICE PATTERN are

GLAUCOMA PREFERRED PRACTICE

Glaucoma Preferred Practice Pattern Panel 2019-2020

Preferred Practice Patterns Committee 2020

Academy Reviewers Association of University Professors in

Glaucoma Preferred Practice Pattern Panel 2019-2020

Preferred Practice Patterns Committee 2020

Secretary for Quality of Care

Primary Open-Angle Glaucoma Suspect Preferred Practice Pattern®

Rationale for Treatment:

OBJECTIVES OF PREFERRED PRACTICE

METHODS AND KEY TO RATINGS

 Key recommendations for care are defined by GRADE2 as follows:

HIGHLIGHTED FINDINGS AND

CLINICAL FINDINGS CHARACTERISTIC OF PRIMARY OPEN-ANGLE

PATIENT OUTCOME CRITERIA

Evaluation of Visual Function

Visual acuity measurement

Confrontation visual fields

Intraocular pressure measurement

pigment dispersion, peripheral anterior synechiae, angle neovascularization, and

Optic nerve head and retinal nerve fiber layer examination

Central corneal thickness measurement

CCT = central corneal thickness

Visual field evaluation

Deciding When to Treat a Glaucoma Suspect Patient

Target Intraocular Pressure

TABLE 2 GLAUCOMA MEDICATIONS

TABLE 2 GLAUCOMA MEDICATIONS (CONTINUED)

To determine the effectiveness of topical therapy, it is necessary to distinguish between the

Special circumstances in pregnancy and during breastfeeding

PROVIDER AND SETTING

COUNSELING AND REFERRAL

Another important question is whether it is cost-effective to screen patients for glaucoma. A

APPENDIX 1. QUALITY OF OPHTHALMIC

Reviewed by: Council

CM = Clinical Modification used in the United States; IOP = intraocular pressure

Additional information for ICD-10 codes:

APPENDIX 3. MANAGEMENT ALGORITHM FOR

APPENDIX 4. LITERATURE SEARCHES FOR

("Glaucoma"[Mesh] OR "Ocular Hypertension"[Mesh] OR “poag suspect”) AND ("Optic Atrophy"[Mesh]

("Glaucoma"[Mesh] OR glaucoma OR "Ocular Hypertension"[Mesh] OR "Intraocular Pressure"[Mesh] OR

("Glaucoma"[Mesh] OR glaucoma OR "Ocular Hypertension"[Mesh] OR "Intraocular Pressure"[Mesh] OR

("Circadian Rhythm"[Mesh] OR "circadian rhythm" OR diurnal OR nocturnal) AND ("Intraocular

(("Glaucoma, Open-Angle"[Mesh] AND suspect*) OR (POAG AND Suspect*) OR “poag suspect” OR

RELATED ACADEMY MATERIALS

Basic and Clinical Science Course Glaucoma (Section 10, 2019–2020)

Ophthalmic Technology Assessment – Free downloads available at

Preferred Practice Pattern® Guidelines – Free downloads available at www.aao.org/ppp.

Clinical Applications of Major Glaucoma Trials (2018)

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(("Glaucoma, Open-Angle"[Mesh] AND suspect) OR (POAG AND Suspect) OR “poag suspect” OR