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Glaucoma Learning Zone
Declaration of sponsorship Novartis Pharma AG

Diagnosing glaucoma

Declaration of sponsorship Novartis Pharma AG
Read time: 30 mins
Last updated:9th Jun 2022
Published:9th Jun 2022

Update your knowledge of the challenges and opportunities in glaucoma diagnosis.

  • Discover the unmet needs in glaucoma diagnosis
  • Explore strategies for screening and early diagnosis of glaucoma
  • Watch videos with glaucoma expert, Professor Anthony King, to learn more

Unmet needs for diagnosing glaucoma

In this video, Professor Anthony King discusses the unmet needs for diagnosing glaucoma, highlighting the benefits of developing screening strategies and improving patient education.

Considering the importance of early diagnosis, yet the difficulty in achieving it, reliable diagnosis of early-stage glaucoma remains an unmet clinical need1

Given that the glaucoma disease process begins up to 20 years before diagnosis is possible, in which time irreversible vision loss may have already occurred, there is a need to develop techniques to diagnose glaucoma earlier, when treatment has a higher chance of improving clinical outcomes2,3. While glaucoma is associated with increased intraocular pressure (IOP)4, and a primary treatment goal is to reduce IOP in order to prevent further optic nerve damage4, measuring changes in IOP and using those measurements to inform diagnosis, treatment and monitoring is problematic for several reasons.

Early glaucoma diagnosis with high specificity and sensitivity

Following age, elevated IOP is the strongest risk factor for primary open angle glaucoma5. However, research indicates that no single value of IOP is sufficiently sensitive or specific enough to detect glaucoma. For instance, although high IOP is a risk factor for glaucoma, high IOP in isolation is not indicative of glaucoma. Conversely, a person with normal IOP values can have glaucoma. IOP alone – in the absence of optic disc examination or visual field test – is therefore not an effective screening tool, and elevated IOP has been found to be a poor case-finding test for glaucoma5,6.

While IOP measurements can help inform diagnosis, treatment and management of glaucoma, one-off IOP measurements taken in clinical practice can be problematic for the following reasons1.

Diurnal variation

  • IOP fluctuates throughout the day due to the circadian rhythm, with maximum and minimum levels typically occurring at daybreak and at the end of the afternoon, respectively. Given these peak fluctuations occurring outside standard clinic hours, it is difficult to detect the presence of increased IOP in this setting4
  • If appointment times vary between clinic visits, IOP readings may be incomparable1
  • Although IOP variations in glaucomatous eyes tend to be higher than in healthy eyes, IOP can vary by as much as 5 mmHg per day in healthy eyes and be unrelated to disease progression or eye damage4

Factors influencing IOP

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Screening and diagnostic strategies for glaucoma

In this video, Professor Anthony King discusses strategies for screening and diagnosing glaucoma. While there are numerous tools that can aid diagnosis, Professor King explains why glaucoma is known as the ‘silent thief of sight’, and highlights the importance of opportunistic case-finding.


Screening

Better screening, diagnosis, monitoring and management of glaucoma are possible thanks to technological advances and enhanced understanding of the disease13.

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References

  1. Cursiefen C, Cordeiro F, Cunha-Vaz J, Wheeler-Schilling T, Scholl HPN. Unmet Needs in Ophthalmology: A European Vision Institute-Consensus Roadmap 2019–2025. Ophthalmic Research. 2019;62(3):123-133.
  2. Shamsher E, Davis BM, Yap TE, Guo L, Cordeiro MF. Neuroprotection in glaucoma: old concepts, new ideas. Expert Review of Ophthalmology. 2019;14(2):101-113.
  3. Nuzzi R, Tridico F. Glaucoma: Biological trabecular and neuroretinal pathology with perspectives of therapy innovation and preventive diagnosis. Frontiers in Neuroscience. 2017;11:494.
  4. Sanchez I, Martin R. Advances in diagnostic applications for monitoring intraocular pressure in Glaucoma: A review. Journal of Optometry. 2019;12(4):211-221.
  5. Chan MPY, Broadway DC, Khawaja AP, Yip JLY, Garway-Heath DF, Burr JM, et al. Glaucoma and intraocular pressure in EPIC-Norfolk Eye Study: cross sectional study. BMJ. 2017;358:j3889.
  6. Bonomi L, Marchini G, Marraffa M, Morbio R. The relationship between intraocular pressure and glaucoma in a defined population. Data from the Egna-Neumarkt Glaucoma Study. Ophthalmologica 2001;215:34-38.
  7. Zhang N, Wang J, Li Y, Jiang B. Prevalence of primary open angle glaucoma in the last 20 years: a meta-analysis and systematic review. Scientific Reports. 2021;11(1):1-12.
  8. Sung H, Shin HH, Baek Y, Kim GA, Koh JS, Park EC, et al. The association between socioeconomic status and visual impairments among primary glaucoma: The results from Nationwide Korean National Health Insurance Cohort from 2004 to 2013. BMC Ophthalmology. 2017;17(1):1-9.
  9. Chakravarti T. The Association of Socioeconomic Status with Severity of Glaucoma and the Impacts of Both Factors on the Costs of Glaucoma Medications: A Cross-Sectional Study in West Bengal, India. Journal of Ocular Pharmacology and Therapeutics. 2018;34(6):442-451.
  10. Oh SA, Ra H, Jee D. Socioeconomic Status and Glaucoma: Associations in High Levels of Income and Education. Current Eye Research. 2018;44(4):436-441.
  11. Wang W, He M, Li Z, Huang W. Epidemiological variations and trends in health burden of glaucoma worldwide. Acta Ophthalmologica. 2019;97(3):e349-355.
  12. Soh Z, Yu M, Betzler BK, Majithia S, Thakur S, Tham YC, et al. The Global Extent of Undetected Glaucoma in Adults: A Systematic Review and Meta-analysis. Ophthalmology. 2021;128(10):1393-1404.
  13. Murthy G, Ariga M, Singh M, George R, Sarma P, Dubey S, et al. A deep dive into the latest European Glaucoma Society and Asia-Pacific Glaucoma Society guidelines and their relevance to India. Indian Journal of Ophthalmology. 2022;70(1):24-35.
  14. Stein JD, Khawaja AP, Weizer JS. Glaucoma in Adults—Screening, Diagnosis, and Management: A Review. JAMA. 2021;325(2):164-174.
  15. Asia Pacific Glaucoma Guidelines. https://www.apglaucomasociety.org/Public/Public/Resources/APGG.aspx. Accessed 16 March 2022.
  16. European Glaucoma Society Terminology and Guidelines for Glaucoma, 5th Edition. British Journal of Ophthalmology. 2021;105(Suppl 1):1-169.
  17. Anton A, Nolivos K, Pazos M, Fatti G, Ayala ME, Martínez-Prats E, et al. Diagnostic Accuracy and Detection Rate of Glaucoma Screening with Optic Disk Photos, Optical Coherence Tomography Images, and Telemedicine. Journal of Clinical Medicine. 2022;11(1).
  18. Hamid S, Desai P, Hysi P, Burr JM, Khawaja AP. Population screening for glaucoma in UK: current recommendations and future directions. Eye. 2021;36(3):504-509.
  19. Recommendation: Glaucoma: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/glaucoma-screening. Accessed 15 March 2022.
  20. Burton MJ, Ramke J, Marques AP, Bourne RRA, Congdon N, Jones I, et al. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020. The Lancet Global Health. 2021;9(4):e489-e551.
  21. Marsden J, Stevens S, Ebri A. How to measure distance visual acuity. Community Eye Health. 2014;27(85):16-16.
  22. What is a Slit Lamp? https://www.aao.org/eye-health/treatments/what-is-slit-lamp. Accessed 16 March 2022.
  23. What Is Gonioscopy? https://www.aao.org/eye-health/treatments/what-is-gonioscopy. Accessed 16 March 2022.
  24. New Tonometry: The Search for True IOP. https://www.aao.org/eyenet/article/new-tonometry-search-true-iop. Accessed 16 March 2022
  25. Sadoughi MM, Einollahi B, Einollahi N, Rezaei J, Roshandel D, Feizi S. Measurement of Central Corneal Thickness Using Ultrasound Pachymetry and Orbscan II in Normal Eyes. Journal of Ophthalmic & Vision Research. 2015;10(1):4.
  26. Broadway DC. Visual field testing for glaucoma – a practical guide. Community Eye Health. 2012;25(79-80):66.
  27. Simons AS, Vercauteren J, Barbosa-breda J, Stalmans I. Shared Care and Virtual Clinics for Glaucoma in a Hospital Setting. Journal of Clinical Medicine. 2021;10(20):4785.
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