How is primary open-angle glaucoma (POAG) treated?

Updated: Mar 16, 2020
  • Author: Kristin Schmid Biggerstaff, MD; Chief Editor: Inci Irak Dersu, MD, MPH  more...
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Some physicians incorrectly treat all elevated IOPs over 21 mm Hg with the above topical medications. Other physicians do not treat unless evidence of optic nerve damage exists, although nerve fiber layer loss of up to 40% may occur before visual field defects occur, so do not treat based on visual field testing alone. Most physicians select and treat those patients thought to be at greatest risk for POAG damage and/or progression (most common approach). See History for a list of risk factors for glaucomatous field loss.

In any case, the goal of treatment is reduction of the pressure before it causes progressive loss of vision. Considering the high average monthly cost of glaucoma medication, along with the possible risks of adverse effects or toxic reactions from drugs, inconvenience of use, and incidence of noncompliance, a strong reason not to treat indiscriminately exists.

Several questions should be asked when considering treatment, to include the following: Is the elevated pressure significant? Will this patient develop visual loss if left untreated? Is the treatment worth the risk of adverse effects of the medications?

One should consider treatment more strongly if the patient reliability or the consequences of missing field loss is an issue (eg, poor reliability on visual field examination, 1-eyed patient, poor availability for follow-up care, younger patient, patient whose optic nerve is difficult to visualize, history of vascular occlusion).

Treatment is highly recommended if signs of damage consistent with glaucomatous optic neuropathy (eg, disc hemorrhage; visible nerve fiber layer defects; notching or vertical ovalization of the cup; asymmetric cupping, especially if >0.7) are observed.

Progressive cupping, even in the absence of visual field loss, can be glaucoma and should be treated as such, although systemic and neurologic workup/correlation for other disorders, including possible neuroimaging studies, should be considered, particularly if there are other nonophthalmologic symptoms. Otherwise, it depends on the assessment of risk factors and benefit of therapy to the patient, as to whether therapy should be initiated.

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