European Glaucoma Society Terminology and Guidelines for Glaucoma, 5th Edition

Foreword The only time is now. Every “now” is unique. Responsible persons ask themselves, “How can I act well now?” The answers will differ for every person, because just as every situation is unique, so is every person different from every other person. But surely there must be some algorithm that will assist us in coming to the right answer. Unfortunately, no, for there is no right answer. There is only an answer that is as appropriate as we can conclude at that moment in that situation. No written guidelines can apply appropriately to every unique situation. Unfortunately we physicians have been suckled on a fallacy: “What’s good for the goose is good for the gander.” Phrased in medical terms, “normal findings are good, and abnormal findings are bad.” This is too simple, and often wrong. Good clinicians know that care must be personalized for it to be optimal. So-called normal findings give rough guidance, sometimes applicable to groups, but frequently wrong for individuals. Consider intraocular pressure (IOP). A normal IOP of 15 mmHg good for some and bad for others, and an abnormal IOP of 30 mmHg is good for some and bad for others. We are so bombarded by the myth of the sanctity of the standard distribution curve that it is hard to think independently and specifically. Also, unfortunately, doctors are prone to decide for patients, often on the basis of normative data that is not relevant or important for the particular patient. That we do this is not surprising, as we want to help, and so we default to what seems to be the easy, safe (non-thinking) way, in which we do not have to hold ourselves accountable for the outcome. Somebody HAS to decide, or else we would be living in an anarchical world. Also true. And because none of us knows as much as we need to know to act appropriately, we seek advice from so-called “experts.” For us to care for people well it is essential that we consider what others recommend. So we look to experts, as we should. However, experts are sometimes right and sometimes wrong. Remember that von Graefe in 1860 recommended surgical iridectomy for all glaucoma, Elliot recommended mustard plaster between the shoulders for glaucoma, Becker based treatment on tonographic findings, Weve reported 100% success with penetrating cyclodiathermy in glaucoma, Lichter advised against laser trabeculoplasty, many thought Cypass was great, and the investigators in the Advanced Glaucoma Intervention Study indicated that an IOP usually around 12 mmHg was better than one usually around 20 mmHg. All wrong. What the authors of these guidelines have done excellently, is to provide a general framework on which ophthalmologists can hang pieces of evidence, so as to be able to evaluate the validity and the importance of that evidence. In doing this meticulously they have provided a valuable service to all ophthalmologists, none of whom individually have either the time or the skill to be fully informed. In their own practices the authors consider whether valid information is relevant for the particular person being considered. That process of considering relevance is essential, always. And relevance is based on the particular unique patient, unique doctor and unique situation. The only guideline the authors can provide in this regard is to remind us all to consider relevance with all patients in all situations, and from the patient’s perspective. Even more important than the service to ophthalmologists is the benefit to patients that will result from thoughtful use of these guidelines. We need, also, to remember that diagnoses are generic, and that within every diagnosis there are differences. For example what does a diagnosis of primary open angle mean? Some of those affected will rapidly go blind despite the most thoughtful treatment and others will keep their sight even without treatment. What does a diagnosis of Chandler’s Syndrome mean? In some, surgery works well, and, in others, poorly. So one never directs diagnosis and treatment at a condition, but rather at the person, the objective being the wellness of that person. The previous European Glaucoma Society Guidelines are used internationally. It is good that the EGS is again providing updated, useful information.The Guidelines are a practical, inspirational contribution. George L. Spaeth, BA, MD. Esposito Research Professor, Wills Eye Hospital/Sidney Kimmel Medical College/Thomas Jefferson University www.eugs.org The Guidelines writers, authors and contributors Augusto Azuara-Blanco ( Editor ) Luca Bagnasco Alessandro Bagnis Joao Barbosa Breda Chiara Bonzano Andrei Brezhnev Alain Bron Carlo A. Cutolo Barbara Cvenkel Stefano Gandolfi Ted Garway Heath Ilmira Gazizova Gus Gazzard Franz Grehn Anders Heijl Cornelia Hirn Gábor Holló Anton Hommer Michele Iester Ingrida Januleviciene Gauti Jóhannesson Miriam Kolko Tianjing Li José Martínez de la Casa Frances Meier-Gibbons Maria Musolino Marta Pazos Norbert Pfeiffer Sergey Petrov Luis Abegao Pinto Riccardo Scotto Ingeborg Stalmans Gordana Sunaric Mégevand Ernst Tamm John Thygesen Fotis Topouzis Marc Töteberg-Harms Carlo E. Traverso ( Editor ) Anja Tuulonen Zoya Veselovskaya Ananth Viswanathan Ilgaz Yalvac Thierry Zeyen Guidelines Committee Augusto Azuara-Blanco ( Chair ) Carlo E. Traverso ( Co-chair ) Manuele Michelessi ( NGP Co-chair ) Luis Abegao Pinto Michele Iester Joao Breda Carlo A. Cutolo Panayiota Founti Gerhard Garhoefer Andreas Katsanos Miriam Kolko Francesco Oddone Marta Pazos Verena Prokosch-Willing Cedric Schweitzer Andrew Tatham Marc Toteberg-Harms Acknowledgements Anja Tuulonen Ted Garway Heath Richard Wormald Tianjing Li Manuele Michelessi Jenny Burr Azuara-Blanco for their methodological oversight. Tianjing Li and Riaz Qureshi (US Cochrane Eye and Vision Group) and Manuele Michelessi (EGS) for leading the evidence review. Manuele Michelessi Gianni Virgili Joao Barbosa Breda Carlo A. Cutolo Marta Pazos Andreas Katsanos Gerhard Garhofer Miriam Kolko Verena Prokosch Panayota Founti Francesco Oddone Ali Ahmed Al Rajhi Tianjing Li Riaz Qureshi and Azuara-Blanco for their contribution to the evidence review. Karen Osborn and Joanna Bradley from Glaucoma UK charity for their contribution to the section: ‘What matters to patients’ ( https://glaucoma.uk ) Additional contributions were made by the following people on specific topics Eleftherios Anastasopoulos Panayiota Founti Gus Gazzard Franz Grehn Anders Heijl Gábor Holló Fotis Topouzis Anja Tuulonen Ananth Viswanatham The team of Clinica Oculistica of the University of Genoa for medical editing and illustrations Luca Bagnasco Alessandro Bagnis Chiara Bonzano Carlo A. Cutolo Michele Lester Maria Musolino Roberta Parodi Riccardo Scotto We would like to thank the following colleagues for their help in reviewing/editing section I.7. Landmark randomised controlled trials for glaucoma Joe Caprioli Ted Garway Heath Gus Gazzard Divakar Gupta Anders Heijl Michael Kass Stefano Miglior David Musch Norbert Pfeiffer Thierry Zeyen External reviews We would like to thank the following societies and experts: World Glaucoma Association: Parul Ichhpujani Monisha Nongpiur Tanuj Dada Sola Olawoye Jayme Vianna Min Hee Suh