Michael V. Boland, MD, PhD; Ann-Margret Ervin, PhD, MPH; David S. Friedman, MD, MPH, PhD; Henry D. Jampel, MD; Barbara S. Hawkins, PhD; Daniela Vollenweider, MD; Yohalakshmi Chelladurai, MBBS, MPH; Darcy Ward, BA; Catalina Suarez-Cuervo, MD; Karen A. Robinson, PhD
Disclaimer: The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Acknowledgment: The authors thank Patrick McKenna, DO, MPH, and Deepa Pawar, MD, MPH, for their assistance in updating the search for this manuscript.
Grant Support: By contract HHSA 290 2007 10061 from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.
Potential Conflicts of Interest: Dr. Boland: Grant (money to institution): AHRQ; Consultancy: Carl Zeiss Meditec, Allergan. Dr. Ervin: Grant (money to institution): AHRQ. Dr. Friedman: Consultancy: Allergan, Bausch & Lomb, Merck, Pfizer, QLT Inc. Dr. Jampel: Consultancy: Ivantis, Transcend, Endo Optics, Allergan, Aerie Pharmaceuticals, Intersect ENT; Stock/stock options: Allergan. Dr. Hawkins: Grant (money to institution): AHRQ; Employment: Johns Hopkins Bloomberg School of Public Health. Dr. Vollenweirder: Grant (money to institution): AHRQ. Dr. Chelladurai: None disclosed. Dr. Suarez-Cuervo: Grant (money to institution): AHRQ. All other authors have no disclosures. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1301.
Requests for Single Reprints: Karen A. Robinson, PhD, Evidence-based Practice Center, Johns Hopkins University Bloomberg School of Public Health, 1830 East Monument Street, Suite 8068, Baltimore, MD 21287.
Current Author Addresses: Dr. Boland: Wilmer Eye Institute, Wilmer 131, 600 North Wolfe Street, Baltimore, MD 21287.
Dr. Ervin: Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, E6146, Baltimore, MD 21205.
Dr. Friedman: Wilmer Eye Institute, Wilmer 120, 600 North Wolfe Street, Baltimore, MD 21287.
Dr. Jampel: Wilmer Eye Institute, Woods 155, 600 North Wolfe Street, Baltimore, MD 21287.
Dr. Hawkins: Wilmer Eye Institute, 550 North Broadway, 9th Floor, Baltimore, MD 21205.
Drs. Vollenweider, Chelladurai, and Suarez-Cuervo and Ms. Ward: Evidence-based Practice Center, Johns Hopkins University, 624 North Broadway, Suite 680, Baltimore, MD 21205.
Dr. Robinson: Evidence-based Practice Center, Johns Hopkins University Bloomberg School of Public Health, 1830 East Monument Street, Suite 8068, Baltimore, MD 21287.
Author Contributions: Conception and design: M.V. Boland, A.M. Ervin, D.S. Friedman, C. Suarez-Cuervo, K.A. Robinson.
Analysis and interpretation of the data: M.V. Boland, A.M. Ervin, D.S. Friedman, H.D. Jampel, B.S. Hawkins, D. Vollenweider, Y. Chelladurai, D. Ward, C. Suarez-Cuervo, K.A. Robinson.
Drafting of the article: M.V. Boland, A.M. Ervin, D.S. Friedman, H.D. Jampel, D. Vollenweider, Y. Chelladurai, C. Suarez-Cuervo, K.A. Robinson.
Critical revision of the article for important intellectual content: M.V. Boland, A.M. Ervin, D.S. Friedman, H.D. Jampel, B.S. Hawkins, D. Vollenweider, C. Suarez-Cuervo, K.A. Robinson.
Final approval of the article: M.V. Boland, A.M. Ervin, D.S. Friedman, H.D. Jampel, B.S. Hawkins, D. Vollenweider, Y. Chelladurai, K.A. Robinson.
Provision of study materials or patients: C. Suarez-Cuervo.
Statistical expertise: A.M. Ervin, D.S. Friedman, D. Vollenweider.
Obtaining of funding: K.A. Robinson.
Administrative, technical, or logistic support: B.S. Hawkins, Y. Chelladurai, D. Ward, C. Suarez-Cuervo, K.A. Robinson.
Collection and assembly of data: M.V. Boland, A.M. Ervin, H.D. Jampel, B.S. Hawkins, D. Vollenweider, Y. Chelladurai, D. Ward, C. Suarez-Cuervo, K.A. Robinson.
Glaucoma is an acquired degeneration of the optic nerve and a leading cause of blindness worldwide. Medical and surgical treatments that decrease intraocular pressure may prevent visual impairment and blindness.
To compare the effectiveness of medical, laser, and surgical treatments in adults with open-angle glaucoma with regard to decreasing intraocular pressure and preventing optic nerve damage, vision loss, and visual impairment.
MEDLINE, CENTRAL, and an existing database for systematic reviews (through 2 March 2011); MEDLINE, EMBASE, LILACS, and CENTRAL for primary studies (through 30 July 2012).
English-language systematic reviews; randomized, controlled trials; and quasi-randomized, controlled trials for most outcomes and observational studies for quality of life and harms.
Two investigators abstracted or checked information about study design, participants, and outcomes and assessed risk of bias and strength of evidence.
High-level evidence suggests that medical, laser, and surgical treatments decrease intraocular pressure and that medical treatment and trabeculectomy reduce the risk for optic nerve damage and visual field loss compared with no treatment. The direct effect of treatments on visual impairment and the comparative efficacy of different treatments are not clear. Harms of medical treatment are primarily local (ocular redness, irritation); surgical treatment carries a small risk for more serious complications.
Heterogeneous outcome definitions and measurements among the included studies; exclusion of many treatment studies that did not stratify results by glaucoma type.
Medical and surgical treatments for open-angle glaucoma lower intraocular pressure and reduce the risk for optic nerve damage over the short to medium term. Which treatments best prevent visual disability and improve patient-reported outcomes is unclear.
Agency for Healthcare Research and Quality.
Summary of evidence search and selection: primary literature.
The sum of the numbers under “Reasons for exclusion” is larger than the total number excluded because multiple reviewers assessed each article. The search identified 11 258 titles; 10 041 were eligible after abstract review. After applying our exclusion criteria, we included 2381 articles for full-text review; we excluded 2002 on the basis of our exclusion criteria and 280 because they were included in previous systematic reviews. For the final analysis, we included 75 RCTs and 24 observational studies addressing adverse effects (16 medical treatment and 8 surgical treatment). FDA = U.S. Food and Drug Administration; IOP = intraocular pressure; RCT = randomized, controlled trial.
* Total may exceed number in corresponding box because articles were excluded by 2 reviewers at this level.
† Total may exceed number in corresponding box because some articles were covered by more than 1 systematic review.
‡ Total may exceed number in corresponding box because articles may apply to more than 1 key question.
§ Other reasons: Comparisons of case series, patient education reports, laboratory or autopsy data, letter or commentaries, drugs out of the list, library could not retrieve.
Summary of evidence search and selection: systematic reviews.
The sum of the numbers under “Reasons for exclusion” is larger than the total number excluded because multiple reviewers assessed each article. We identified 169 systematic reviews from the search in the databases. After exclusion at abstract level, we included 48 for full-text review. From those we excluded 25 on the basis of quality criteria. We included for our review a total of 23 systematic reviews. Eleven reviews addressed the comparative effectiveness of medical treatment of open-angle glaucoma, 10 addressed questions of surgical treatment, and 2 compared medical versus surgical treatments for open-angle glaucoma. One additional review addressed the comparative effectiveness of glaucoma surgeries versus one another as well as surgeries versus medical treatments for open-angle glaucoma.
Table. Evidence Available for Visual Impairment and Patient-Reported Outcomes
Appendix Table 1. Evidence Available for the Outcome of Reduced Intraocular Pressure
Appendix Table 2. Evidence for the Outcomes of Visual Field Loss and Optic Nerve Damage
Appendix Table 3. Evidence for Harms Associated With Treatments for Open-Angle Glaucoma
Evidence addressing the key outcomes of patient-reported outcomes, visual disability, visual field or optic nerve damage, and intraocular pressure.
The studies are also categorized according to the interventions being compared: medical, surgical, or medical vs. surgical. Primary studies and systematic reviews are indicated with dots, with the size of the circle proportional to the number of participants. RCT = randomized, controlled trial.
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Michael V. Boland, Ann-Margret Ervin, David S. Friedman, Henry D. Jampel, Barbara S. Hawkins, Daniela Vollenweider, et al. Comparative Effectiveness of Treatments for Open-Angle Glaucoma: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med. 2013;158:271–279. doi: 10.7326/0003-4819-158-4-201302190-00008
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Published: Ann Intern Med. 2013;158(4):271-279.
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