Glaucoma: USPSTF Deems Evidence for Screening Insufficient

Laurie Barclay, MD

July 08, 2013

The US Preventive Services Task Force (USPSTF) has determined that the evidence is insufficient to weigh the balance of benefits and harms of screening for primary open-angle glaucoma (POAG) in adults, according to their final recommendation statement, by Virginia A. Moyer, MD, MPH, from the American Board of Pediatrics, Chapel Hill, North Carolina, published online July 9 in the Annals of Internal Medicine and on the USPSTF Web site.

The new guidelines, which update the 2004 USPSTF recommendation on glaucoma screening, were posted in draft form for public comment in February 2013.

"Glaucoma is a serious disease that can cause vision problems and blindness in millions of Americans," Albert Siu, MD, MSPH, task force co-vice chairman, said in a news release. "Unfortunately, we don't have enough evidence to know how best to screen for the disease and who would benefit from screening in the primary care setting."

POAG is the most prevalent type of glaucoma, affecting about 2.5 million Americans. Risk factors include older age and black race. Because of the slow progression of POAG, symptoms of gradual vision loss may not be detected until the disease is advanced.

The "I statement" means the task force cannot at this time recommend for or against screening because there is not enough evidence to evaluate the accuracy and efficacy of glaucoma screening in primary care settings for adults without visual impairment.

Underlying Evidence

Before issuing their statement, the USPSTF reviewed evidence regarding the accuracy of glaucoma screening tests and the benefits and harms of screening for glaucoma and of medical and surgical treatment of early glaucoma. Potential benefits include improved vision-related quality of life and reduced progression of early asymptomatic glaucoma to vision-related impairment.

The lack of an established gold standard against which individual screening tests can be compared limits the evidence on screening accuracy.

In addition, evidence is lacking that screening for or treatment of asymptomatic POAG lowers the risk for vision loss and blindness. However, evidence is convincing that treating increased intraocular pressure and early glaucoma reduces the number of persons who develop small, clinically unnoticeable visual field defects, as well as that treating early, asymptomatic POAG reduces the number of persons whose visual field defects worsen.

There was no direct evidence of the harms of screening, but there was convincing evidence that treatment results in numerous harms, including local eye irritation from medications and risk for surgical complications, such as early cataract formation. For most persons, the magnitude of these harms is small.

Recommendations

For asymptomatic individuals, expert guidance may determine what, if any, screening is indicated for the specific patient's needs.

Patients with vision problems should continue to be tested and treated according to the judgment of their primary care provider or ophthalmologist.

"We call on the health care community to conduct critically needed research on effective screening tests and treatments for glaucoma," Dr. Siu said in the release. "Findings from new research may be able to improve the lives of many Americans and help the Task Force update its recommendation in the future."

The authors have disclosed no relevant financial relationships.

Ann Intern Med. Published online July 9, 2013.

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